- You are thinking about the test you have next week, and you are really concerned
because you have not done well on past tests. You notice that your heart is beating a little
faster than usual. You are most likely experiencing anxiety.
- Fear
o Emotion of an immediate alarm reaction to present danger or life threatening
emergencies.
o The present-oriented mood state
o Involves abrupt activation of the sympathetic nervous system
―Fight or Flight‖
o Strong avoidance/ escapist tendencies
o Marked negative affect
- Imagine that you are driving your car when someone in another car suddenly pulls out in
front of you. It seems that you are going to crash into the other car, but you are able to
brake and prevent an accident. As you continue driving, you notice that your heart is
racing, your breathing is more rapid than usual, and you feel a little dizzy. What is the
name of this experience? – Fight or Flight
- Panic
o Sudden, overwhelming fright or terror
o Panic attack – Abrupt experience of intense fear or discomfort accompanied
by several physical symptoms, such as dizziness or heart palpitations.
o Three basic types of panic as described in DSM-IV-TR:
Situationally bound (cued)
Unexpected (uncued)
Situationally predisposed
Unexpected and Situationally predisposed attacks are important in
panic disorders. Situationally bound attacks are more common in
specific phobias or social phobias.
- Mark always has panic attacks when he is in elevators but never in other circumstances.
His panic attacks are known as Situationally bound.
- What biological system connects the septal and hippocampal area of the limbic system to
the cortex, and when activated, causes a person to feel anxious and to apprehensively
evaluate a situation to determine whether danger is present? – Behavioral Inhibition
System
- A man reports difficulty sleeping, distractibility, and stomachaches for the past six
months. During this time, he has been worrying a lot about his mother's health, his
daughter's difficulties in school, and his performance at work; he spends a lot of time
worrying, and feels that he can't stop himself. What is the most likely diagnosis? –
General Anxiety Disorder
- What kind of cognitive bias do people with GAD have, compared to people who do not
have GAD? – They automatically and quickly focus their attention on potential
threats.
o Major Problem with the Field: Correlation Does Not Mean Causation!
We can’t do experiments: that would require us giving some people GAD
and not giving it to others.
So: people who do or do not fit the stereotype for GAD or whatever
disorder are being compared.
People, who differ in two ways, differ in 3 ways, 5 ways, in fact millions
of ways!
Any one of those unmeasured ways can cause the relationship you are
looking at.
Science searches for answers (at least in part) by eliminating competing
hypotheses.
But it is impossible to eliminate the hypothesis that some other
unmeasured variables caused the two variables to a correlational
study to have a relationship with each other.
We can’t make causal inferences based on correlation because we
can’t eliminate the hypothesis that one of these other (unstudied,
and often not feasible to study) factors is the causal agent.
o We must know what will directly cause change
o Treatment of GAD: Generally weak
Benzodiazepines – often prescribed
Antidepressants
Psychological interventions – cognitive-behavioral therapy
Meditation therapy
Combined treatments – acute vs. long-term outcomes
- According to the text, benzodiazepines are the most frequently prescribed drugs for
GAD.
- The part of the brain that is believed to be responsible for panic disorder is the
amygdala.
- Why are the majority of people who suffer from agoraphobia women? -- It is more
accepted for women to report fear and to avoid numerous situations
o Causes
Triple Vulnerability Model
We all inherit—some more than others—a vulnerability to stress, which is
a tendency to be generally neurobiologically over-reactive to the events of
daily life (generalized biological vulnerability).
But some people are also more likely than others to have an emergency
alarm reaction (unexpected panic attack) when confronted with stress-
producing events.
8% to 12% has occasional attacks vulnerability
o Associated Features
Nocturnal panic attacks – 60% panic during deep non-REM sleep
Interoceptive avoidance – avoidance of internal physical sensations
o Medication Treatment
Target serotonergic, noradrenergic, and GABA systems
SSRIs (e.g., Prozac and Paxil) are preferred drugs
Relapse rates are high following medication discontinuation
o Psychological and Combined Treatments
Cognitive-behavioral therapies are highly effective
No evidence that combined treatments produces better outcome
Best long-term outcome is with cognitive-behavioral therapy alone
Panic Control Treatment (PCT) – Cognitive-behavioral treatment for
panic attacks, involving gradual exposure to feared somatic sensations
and modification of perceptions and attitudes about them.
Combined psychological and drug treatments
Innovative approaches
Psychological (CBT) treatment followed by drug treatments
D-cycloserine (DCS)
- A major study sponsored by the National Institutes of Mental Health examined various
treatments for panic disorder. Which of the following was found to be most effective long
term (six months after treatment ended)? – Cognitive-Behavioral Treatment alone
Figure 4.6 Responders Based on the Panic Disorder Severity Scale Average Item
Score after Acute and After Maintenance Conditions
Figure 4.7 A Model of the Various Ways a Specific Phobia may Develop
- When exposed to the object of their phobia, most people with specific phobia show an
increase in heart rate and blood pressure. In contrast, which subtype involves decreased
heart rate and blood pressure, and possible fainting? – Blood-Injection -Injury
- A child with separation anxiety disorder has the fear that something bad will happen to
him or his parents.
o Causes of Phobias
Direct experience
Biological and evolutionary vulnerability
Traumatic conditioning, prepared tendency, event will happen again
o Psychological Treatments of Specific Phobias
Cognitive-behavioral therapies are highly effective – exposure
Require structured and consistent exposure-based exercise under
therapeutic supervision
- Which technique appears to be the most effective treatment for phobias? – structured
and consistent exposure to the feared stimulus under therapeutic supervision
o Cultural Factors
The prevalence of specific phobias varies from one culture to another.
- A woman has always disliked clowns. However, she has very few encounters with them.
When she does, she feels uncomfortable. She makes no effort to approach them, but she
also makes no effort to avoid them. Which of the following best applies to this woman?
Figure 4.8 A Model of the Various Ways a Social Phobia May Develop
o Causes
Biological and evolutionary vulnerability
Similar learning pathways as specific phobias
Three pathways to social phobias:
Generalized biological vulnerability to develop anxiety
Biological tendency to be socially inhibited
Both
The existence of a generalized psychological vulnerability would increase
an individual's vulnerability.
o Psychological Treatment
Cognitive-behavioral treatment (CBT)
Cognitive-behavioral group treatment (CBGT)
Cognitive-behavioral therapies are highly effective
o Medication Treatment
Tricyclic antidepressants and monoamine oxidase inhibitors more
effective than placebo in the treatment of severe social anxiety.
SSRIs Paxil, Zoloft, and Effexer – are FDA approved
Relapse rates are high following medication discontinuation
- A man who persistently worries about being humiliated or embarrassed when talking to
women is showing signs of social phobia.
- According to the text, three pathways to social phobia are possible. Which of the
following is NOT one of these? – generalized psychological vulnerability to believing
that stressful events are potentially uncontrollable.
- Which of the following drugs has NOT been shown to be effective (compared to placebo)
in the treatment of social phobia? – beta-blockers.
- Which of the following must occur in order for a person to develop posttraumatic stress
disorder? – experiencing a traumatic event
o Statistics
Combat and sexual assault are the most common traumas.
Soldiers face combat again and again
Rape victims think about what happened to them. Relive it again
and again
PTSD is basically a disorder based on adrenalin.
General rule: Too much adrenalin for too long a period and you wind up
with PTSD
o Subtypes and Associated Features of PTSD
Acute – may be diagnosed one-three months post trauma
Chronic – diagnosed after three months post trauma
Delayed onset – onset six months or more post trauma
Acute Stress Disorder – PTSD immediately post trauma
- How is acute stress disorder (ASD) different from posttraumatic stress disorder (PTSD)?
– ASD occurs right after a traumatic event, and PTSD occurs one month to many
years later.
o Causes of PTSD
Intensity of the trauma and one’s reaction to it (i.e., true alarm)
Learn alarms – direct conditioning and observational learning
Biological vulnerability
Uncontrollability and unpredictability
o Treatment
Psychological Treatments
Catharsis – reliving emotional trauma to relieve emotional
suffering
Cognitive-behavioral therapies (CBT) are highly effective
CBT may include graduate or massed (e.g., flooding) imaginal
exposure
o Content of the trauma and the emotions associated with it
are worked through systematically
Aim of CBT for PTSD
o Work with the victim to develop a narrative of the
traumatic experience that is then reviewed extensively in
therapy.
o Cognitive therapy to correct negative assumptions about
the trauma, such as blaming oneself in some ways, feeling
guilty, or both, is often part of treatment
Any exposure technique will do: EMDR – Eye Movement
Desensitization Reprocessing
o Psychological method that helps people to quickly process
and heal from the emotional distress that lodges in their
minds following traumatic incidents
o EMDR to be highly effective in treating the incapacitating
memories and intense emotions associated with
psychological trauma
- Researchers have identified protective factors that help prevent the development of PTSD
after a person experiences a traumatic event. All of the following are protective factors
EXCEPT becoming angry and placing blame on others.
o OCD: Treatment
Medication treatment
Most effective seem to be those that specifically inhibit the
reuptake of serotonin
Clomipramine and other SSRIs – benefits up to 60% of patients
Relapse is common with medication discontinuation
Psychosurgery (cingulotomy) is used in extreme cases
Psychological treatment
Cognitive-behavioral therapy is most effective
CBT involves exposure and response prevention
Combining CBT with medication – no better than CBT alone
Exposure and ritual prevention (ERP) – more effective than drugs
o A process whereby the rituals are actively prevented and
the patient is systematically and gradually exposed to the
feared thoughts or situations.
- Julie constantly worries that her house will burn down if she does not unplug and check
all of her electrical appliances before she leaves the house. She has developed a routine of
unplugging and checking that takes her about 1 hour to complete before she can leave
home. After performing this routine, she feels a little less anxious, although her anxiety
quickly returns after she leaves. Even though Julie recognizes that her actions are
excessive, she feels like she has no control over these behaviors. Based on these
symptoms, what problem does Julie seem to have? – obsessive-compulsive disorder
- Connor believes that he must pray every time he thinks a bad thought about his mother or
father. This is known as thought-action fusion.
- Which of the following is NOT true about treatment for OCD? -- The type of
medication typically used to treat OCD is a psychostimulant.
Somatoform Disorders
- Somatoform disorder – Pathological concern of individuals with the appearance or
functioning of their bodies, usually in the absence of any identifiable medical condition.
- Dissociative disorder – Disorder in which individuals feel detached from themselves
or their surroundings and feel reality, experience, and identity may disintegrate.
o Soma – meaning ―body‖
Preoccupation with health and/or body appearance and functioning
Aside from hypochondriasis, no identifiable medical condition causing the
physical complaints.
Hypochondriasis – Somatoform disorder involving severe anxiety
over belief in having a disease process without any evident
physical cause.
This means you make the diagnosis of somatoform disorder by excluding
all possible medical conditions.
Since we don’t know everything that can happen, can only exclude
disorders you thought of
o Types of DSM-IV-TR Somatoform Disorders
Hypochondriasis – Somatoform disorder involving severe anxiety over
belief in having a disease process without any evident physical evidence.
Preoccupation with fears of having a serious disease despite
appropriate medical evaluation
Not a delusionary intensity and is not restricted to concern over
physical appearance.
Clinically significant distress or impairment because of
preoccupation
Duration of 6 months
Somatization disorder ; old diagnosis = hysteria
Somatoform disorder involving extreme and long-lasting focus on
multiple physical symptoms for which no medical cause is evident.
Conversion disorder ; old diagnosis = hysteria
Physical malfunctioning, such as blindness or paralysis, suggesting
neurological impairment but with no organic pathology to account
for it.
Pain disorder; old diagnosis = hysteria.
Somatoform disorder featuring true pain but for which
psychological factors play an important role in onset, severity, or
maintenance.
Pain disorder is unfortunately common
Body dysmorphic disorder ; something different
Somatoform disorder featuring a disruptive preoccupation with
some imagined defect in appearance (―imagined ugliness‖).
o Hypochondriasis DB view is that they are taking minor meaningless sensations
too seriously – Again
o Clinical Description
Physical complaints without a clear cause
Severe anxiety about the possibility of having a serious disease – Doesn’t
this look like an anxiety disorder
Strong disease conviction
Medical reassurance does not seem to help
Patients with hypochondriasis are not supposed to benefit from
reassurance about their health
Reassurances from numerous MDs that all is well and the
individual is healthy have, at best, only a short term effect.
MD shopping; boutique medical practice
It isn’t long before patients are back in the office of another doctor
on assumption that the previous doctor missed something.
o Compared with GAD
Hypochondriasis looks like an anxiety disorder.
Tough to distinguish
o Statistics
Good prevalence data are lacking
Unique to women, however, the Sex Ratio is actually closer to 50:50
Onset at any age
Runs a chronic course
o Causes
Cognitive perceptual distortions
Basically a disorder of cognition or perception with strong
emotional contributions
Enhanced perceptual sensitivity to illness cues
Also tend to interpret ambiguous stimuli as threatening
Familial history of illness
Most similar disorder = GAD, more anxiety disorder than like other
somatoform disorder
Three other factors:
Develop in the context of a stressful life event (e.g., death or
illness)
Disproportionate incidence of disease in their family when they
were children
o Carry strong memories of illness that could easily become
the focus of anxiety
An important social and interpersonal influence may be operating
o ―sick role‖ – benefits of being sick; receives increased
attention for being ill
o Treatment
We all know these don’t work well – at least add gatekeeper physician
Gatekeeper Physician: A general term that refers to health plans
that attempt to control the cost and quality of care by coordinating
medical and other health-related services.
Cognitive Behavioral Treatment (CBT) – Identify and Challenge illness-
related misinterpretations
Provide more substantial and sensitive reassurance
Mental health professionals devote more time to all concerns the
patient might have and attend more time to the ―meaning‖ of the
symptoms
Stress management and coping strategies
Same type of drugs (antidepressants) are useful for anxiety and depression
- Somatization Disorder
o Clinical Description
Extended history of physical complaints before age 30
Substantial impairment in social or occupational functioning
Concern about the symptoms, not what they might mean
Symptoms become the patient’s identity
No physical reason for the symptoms – this one is so obvious, people
miss it.
People with only a few medically unexplained physical symptoms may
experience sufficient distress and impairment of functioning to be
considered undifferentiating somatoform disorder.
Just a somatoform disorder with fewer than eight symptoms.
o Statistics
Rare condition
Onset usually in adolescence
Mostly affects unmarried, low socioeconomic single (SES) women
Runs a chronic course
The rates are relatively uniform around the world for medically
unexplained physical symptoms, as is the sex ratio.
When the problem is severe enough to meet criteria for disorder,
the sex ratio is approximately 2:1 female to male.
o Causes
Familial history of illness
Relation with antisocial personality disorder
Weak behavioral inhibition system
MISSED DIAGNOSIS OR MISDIAGNOSIS OF A
PHYSIOLOGICALLY BASED DISORDER
- Somatization disorder is strongly linked, through family and genetic studies, to antisocial
personality disorder.
o Treatment
Rob Woolfolk and Dr. Leslie Allen have pioneered the use of a form of
CBT with a little Gestalt and Mindfulness – modest, but positive, results
Reduce the tendency to visit numerous medical specialists
Assign ―gatekeeper physician‖
Reduce supportive consequences of talk about physical symptoms
- Pain Disorders
o Psychological factors play an important role in maintaining pain, particularly
anxiety focused on the experience of pain
Judged to play primary role in the onset, severity, exacerbation, or
maintenance of the pain
o Comes in two types: Acute and Chronic
o Acute pain occurs when there is damage to the body that will either heal or kill
you.
i.e., Bruising a limb and the pain of surgery are examples
Most important enemy is anxiety – treat anxiety with hypnosis, distraction
& relaxation.
o An important feature of pain disorder is that pain is REAL and it HURTS,
regardless of the cause.
o One reason that it is difficult to diagnose pain disorder is that the experience of
pain usually involves some level of both physical and psychological factors.
o Munchausen Syndrome
Munchausen Syndrome by proxy – deliberate actions directed towards
making a child sick
Co-workers who create problems just so they can solve them later and take
credit for it.
Malingering – Deliberate faking of a physical or psychological
disorder motivated by gain.
Factitious disorders – Nonexistent physical or psychological disorder
deliberately faked for no apparent gain except, possibly, sympathy and
attention.
- Mrs. Thompson brought her 4-year-old daughter, Carmen, to the emergency room stating
that the child had been vomiting nonstop throughout the morning. Carmen's condition
improved over the course of several days. On the day of her discharge from the hospital,
a nurse walked in as Mrs. Thompson was giving Carmen a drink of floor cleaner. Mrs.
Thompson's behavior is consistent with Munchausen syndrome by proxy.
o Treatment
Similar to somatization disorder
Core strategy is attending to the trauma
Remove sources of secondary gain
Reduce supportive consequences of talk about symptoms
About 50% missed diagnoses
Hypnotherapists with doctoral degree get sent these patients
Lengthy discussions with fellow hypnotherapists strongly suggest
that we refer many patients to more competent facilities and about
50% of those referred to us wind up being diagnosed with a
physical disorder which, when fixed, gets rid of the problem.
It could be worse, and may have been.
A study in the early 1960s in Ireland followed 20 patients formally
diagnosed with ―hysteria‖, that is, with having symptoms for
which there was no physical basis.
Within two years, all but 2 of them were diagnosed with a physical
disorder that accounted for the symptoms
Either the mind has yet undiscovered effect on the body, or we had
18 misdiagnoses.
- During the development of conversion disorder, the reduction in anxiety that occurs after
the anxiety has been converted into physical symptoms is known as primary gain.
- Jason believes that his nose is unusually large, ugly, and out of proportion to his face
(objective observers would say that his nose is average). When he sees or talks to
someone, Jason believes that the other person is looking only at his nose, thinking about
how huge and ugly it is. When he is in any public setting, Jason is constantly worrying
about others looking at his nose. He does not have any other social concerns.
Nonetheless, Jason avoids social situations as much as possible. These problems cause
significant impairment in Jason's life. Which of the following best describes Jason's
symptoms? – body dysmorphic disorder
- Losing your sense of the reality of the external world is called derealization.
o Depersonalization Disorder
Overview and Defining Features
Dissociative disorder in which feelings of depersonalization are
so severe they dominate the individual's life and prevent normal
functioning.
Severe and frightening feelings of unreality and detachment
Feeling dominate and interfere with life functioning
o Primary problem involves depersonalization and
derealization
The diagnosis of depersonalization disorder is quite rare and
only applied when the experience of depersonalization
interferes with normal functioning
Facts and Statistics
High comorbidity with anxiety and mood disorders
Onset is typically around age 16
Usually runs a lifelong chronic course – if taken seriously
Causes
Is it just taking relatively normal experiences too seriously?
o Alternatively, as in panic disorder, are the experiences of
those whose lives are adversely affected more
serious/frightening and so on.
o Cognitive deficits in attention, short-term memory,
spatial reasoning
o Deficits related to tunnel vision and mind emptiness
o Such people are easily distracted
Treatment
Little is known, but extinction might work here
You could create the experiences with hypnosis or use other
methods
o Experience it, then live through it, thus demonstrating that
there is nothing to be afraid of
Remember treatment for panic attacks: the stubbed toe approach +
panic control treatment
- Studies have shown that individuals with depersonalization disorder have cognitive
deficits in all of the following areas EXCEPT general intelligence.
o Dissociative Amnesia
Most psychopathology can be understood as a response to stress combined
with social norms and biological vulnerability
Name = ―dissociative‖ disorders partially a matter of history and politics
Problem not necessarily involved with splitting of consciousness
When real, such problems are really rare
Dissociative amnesia – Dissociative disorder featuring the inability to
recall personal information; usually of a stressful or traumatic nature.
Includes several forms of psychogenic memory loss
Generalized vs. localized or selective type
o Generalized amnesia – Loss of memory of all personal
information, including identity.
o Localized or Selective amnesia – Memory loss limited to
specific times and events, particularly traumatic events.
- The disorder called amok illustrates the fact that mental illnesses are culturally defined.
- Another word for separate identities found in dissociative disorders is host identities.
- Dr. Jones tells his class that therapists are in a position to suggest the existence of alters,
which then can lead to a diagnosis of DID. Dr. Jones is explaining the sociocognitive
model.
- What research evidence suggests that at least some people with dissociative identity
disorder are not consciously and voluntarily simulating alters? –
Statistics
Pre-Sybil, average number of identities was about 2 to start, with a
3rd resolving the problem
o Since Sybil, average number of identities recently is close
to 15 – about as many as Sybil
Ratio of females to male is very high (9:1)
o This is unusual – Gender ratios seldom much above 2:1
Onset is almost always in childhood (but DID in kids is rarely
reported. And kids are under fairly constant view of some adult.)
High comorbidity rates & lifelong, chronic course
- Research has shown that a large percentage of individuals with DID may have concurrent
diagnoses of all of the following EXCEPT eating disorders.
- The autohypnotic model suggests that individuals who are hypnotizable may be able to
use dissociation as a response to severe trauma.
Obesity Treatment
Treatment
o Moderate success with adults
o Greater success with children and adolescents
Treatment progression – from least to most intrusive options
First Step
o Self-directed weight loss programs
Second Step
o Commercial self-help programs
Third Step
o Behavior modifications programs
Last Step
o Bariatric surgery
Medical Treatments
Insomnia
o Benzodiazepines and over-the-counter sleep medications
o Prolonged use
Can cause rebound insomnia, dependence
o Best as short-term solution
Hypersomnia and narcolepsy
o Stimulants (i.e., Ritalin)
o Cataplexy
Usually treated with antidepressants
Breathing-related Sleep Disorders
o May include medications, weight loss, or mechanical devices
Circadian Rhythm Sleep Disorders
o Phase delays
Moving bedtime later (best approach)
o Phase advances
Moving bedtime earlier (more difficult)
o Use of very bright light
Trick the brain’s biological clock
Environmental treatments
Psychological Treatments
Relaxation and stress reduction
o Reduces stress and assists with sleep
o Modify unrealistic expectations about sleep
Stimulus control procedures
o Improved sleep hygiene – bedroom is a place for sleep
o For children – setting a regular bedtime routine
Combined treatments
o Insomnia – short-term medication plus psychotherapy
o Other dyssomnias
Little evidence for the efficacy of combined treatments
- Sleep Disorders
- What are the critical diagnostic features of the major sleep disorders?
o Sleep disorders are highly prevalent in the general population and are of two
types: dyssomnias (disturbances of sleep) and parasomnias (abnormal events such
as nightmares and sleepwalking that occur during sleep).
o Of the dyssomnias, the most common disorder, primary insomnia, involves the
inability to initiate sleep, problems maintaining sleep, or failure to feel refreshed
after a full night's sleep. Other dyssomnias include primary hypersomnia
(excessive sleep), narcolepsy (sudden and irresistible sleep attacks), circadian
rhythm sleep disorders (sleepiness or insomnia caused by the body's inability to
synchronize its sleep patterns with day and night), and breathing-related sleep
disorders (disruptions that have a physical origin, such as sleep apnea, that lead to
excessive sleepiness or insomnia).
o The formal assessment of sleep disorders, a polysomno-graphic evaluation, is
typically done by monitoring the heart, muscles, respiration, brain waves, and
other functions of a sleeping client in the lab. In addition to such monitoring, it is
helpful to determine the individual's sleep efficiency, a percentage based on the
time the individual actually sleeps as opposed to time spent in bed trying to sleep.
- What medical and psychological treatments are used for the treatment of sleep disorders?
o Benzodiazepine medications have been helpful for short-term treatment of many
of the dyssomnias, but they must be used carefully or they might cause rebound
insomnia, a withdrawal experience that can cause worse sleep problems after the
medication is stopped. Any long-term treatment of sleep problems should include
psychological interventions such as stimulus control and sleep hygiene.
- How are rapid eye movement and nonrapid eye movement sleep related to the
parasomnias?
o Parasomnias such as nightmares occur during rapid eye movement (or dream)
sleep, and sleep terrors and sleepwalking occur during nonrapid eye movement
sleep.