ABP 02: Anxiety, Trauma, OCD, Somatic, DID

• Anxiety


  Negative mood state characterized by body symptoms of physical tension and by apprehension about the future
• Fear


  An immediate alarm reaction to danger
• Panic


  Sudden overwhelming reaction
• Panic Attack


  Abrupt experience of intense fear or acute discomfort, accompanied by physical symptoms
• Types of Panic Attacks

  • Expected (Cued) - if you have a clue of what/where situations a panic attack could occur
  • Unexpected (Uncued) - if you don't have a clue when/where the next attack will occur
• Biological Contributions to Anxiety

  • We inherit the tendency to be tense, uptight, and anxious
  • Low GABA levels = increased anxiety
  • Low Serotonin = increased anxiety
  • Corticotropin-Releasing Factor (CRF) activates Hypothalamic-Pituitary-Adrenocortical (HPA) axis which has a wide-ranging effects on areas of the brain implicated in anxiety
  • Limbic System - mediator between the brain stem and the cortex that is most often associated with anxiety
  • Behavioral Inhibition System - activated by signals from the brain stem of unexpected events
  • Fight/Flight System (FSS) - produces an immediate alarm-and-escape response that looks very much like panic in humans
  • FFS is activated partly by the deficiencies in serotonin
• Psychological Contributions to Anxiety

  • Freud: anxiety was a psychic reaction to danger surrounding the reactivation of an infantile fearful situation
  • Behaviorists: Anxiety was a product of learning (Conditioning, Modeling, or other forms of learning)
  • In childhood, we may acquire an awareness that events are not always in our control - the continuum of this perception may range from total confidence in our control of all aspects of our lives to deep uncertainty about ourselves
  • The way parents who interact with their children by responding to their needs contributes to the development of anxiety
  • Anxiety Sensitivity: appears to be an important personality trait that determines who will and who will not experience problems with anxiety under certain stressful conditions
• Social Contributions to Anxiety

  • Stressful life events trigger our biological and psychological vulnerabilities
  • Repeated denials of their true thoughts, emotions and behavior make these people extremely anxious
  • Children who fail to receive unconditional positive rewards may be over critical of themselves and develop harsh self-standards
  • Many people are guided by irrational beliefs that lead them to act in inappropriate ways (Basic Irrational Assumptions)
  • People with GAD constantly hold silent assumptions that imply they are in imminent danger
  • Metacognitive Theory (Wells): people with GAD implicitly hold both positive and negative beliefs about worrying; they believe that worrying is a useful way of appraising and coping with threats of life
  • Intolerance of Uncertainty Theory: certain individuals cannot tolerate the knowledge that negative events may occur
  • Avoidance Theory: people with GAD have greater bodily arousal and that worrying reduces this arousal
• Triple Vulnerability Theory


  • Generalized Biological Vulnerability; 2) Generalized Psychological Vulnerability; and 3) Specific Psychological Vulnerability
• Generalized Anxiety Disorder (GAD)


  • Individuals with GAD do not respond as strongly to stressors as individuals with anxiety disorders in which panic is prominent
  • Low cardiac vagal tone, leading to autonomic inflexibility
  • May have arisen in early stressful experiences where they learned the world is a dangerous place
  • Intense cognitive processing in the frontal lobs as indicated by EEG activity, particularly in the left hemisphere
  • Intense worrying may act as avoidance
  • Treatment: Benzodiazepines (but creates dependence to it) & Cognitive-Behavioral Treatment (beneficial for long-term), Rational-Emotive Therapy
  • Rarely occur prior to adolescence; may occur early in life but manifested as anxious temperament
  • Worry whether or not they are being judged/evaluated
  • May worry about separation but could also worry about other things
  • Worry about multiple events, situations, or activities
  • Focus of the worry is about forthcoming problems
  • Women diagnosed with this disorder outnumber men 2 to 1
  • Children experience some degree as part of growing up and that all use ego defense mechanisms; their defense mechanisms are particularly inadequate
  • Fear Circuit is excessively active
  • Improper functioning by various neurons, structures, interconnections, or other neurotransmitters throughout the fear circuit
• Panic Disorder (PD)


  • Mean age at onset is 34.7 yrs
  • Very rare in childhood
  • Chronic in adolescence and comorbid with other disorders
  • PD shouldn't be diagnosed if full-symptom panic attacks was never experienced
  • PD is not diagnosed with panic attacks are direct physiological consequence of another medical conditions or substance
  • Norepinephrine activity is indeed irregular in people who suffer from panic attacks
  • Susto - disorder that is characterized by sweating, increased heart rate, and insomnia but not by reports of anxiety or fear, even though a severe fright is the cause
  • Ataques De Nervios - quite similar to panic attack but with shouting or bursting into tears
  • Kyol Goeu - wind overload, too much wind or gas in the body which may cause blood vessels to burst
  • Nocturnal Panic - occur during delta wave or slow wave sleep, which typically occurs several hours after we fall asleep and is the deepest stage of sleep
• Agoraphobia


  • Agoraphobia develops after a person has unexpected panic attacks
  • Initial Onset: before 35 yrs old, with 21 yrs the mean age
  • Persistent and chronic
  • If the fear, anxiety is limited to one of the agoraphobic situation, the Specific Phobia must be diagnosed
  • Although we all typically experience rapid heartbeat, if you have psychological or cognitive vulnerability, you might interpret the response as dangerous and feel a surge of anxiety
  • Early object loss and/or separation anxiety predispose to someone to develop the condition as an adult
• Separation Anxiety Disorder (SepAnx)

  • Onset: early as preschool age and may occur some time during childhood and adolescence
  • In SepAnx, threats of separation from close attachments may lead to extreme anxiety and panic attacks
  • SepAnx is not responsible for school absences or school avoidance
  • School refusal in SepAnx may be common but due to fear of being away with attachment figures
  • SepAnx = fear of POSSIBLE separation is the central thought
  • SepAnx concern about the proximity and safety of key attachment figures
  • Treatment: High-Potency Benzodiazepines, SSRIs, closely related serotonin-norepinephrine reuptake inhibitors, Panic Control Treatment, Exposure exercises, CBT
• Types of Specific Phobias

  • Blood-Injection-Injury Phobia
  • Situational Phobia
  • Nature Environment Phobia
  • Animal Phobia
• Specific Phobia


  • Irrational fear of a specific object or situation that markedly interferes with an individual's ability to function
  • Acquired through direct experience, experiencing in false alarm, and observing others
  • Usually develops in early childhood
  • Situational phobias tend to have a later age at onset
  • Women: Men, 2:1
  • Treatment: Exposure-based exercises
• Social Anxiety Disorder (Social Phobia)


  • Fearful of scrutiny by others
  • Panic attacks are always cued by social situations and do not occur "out of the blue"
  • Typically have adequate age-appropriate social relationships and social communication capacity
• Selective Mutism


  • Rare childhood disorder characterized by a lack of speech in one or more setting in which speaking is socially expected
  • Usually before age 5 yrs
  • Many individuals outgrow selective mutism
  • Restricted to specific social situation
  • Should be diagnosed only when a child has an established capacity to speak in some social situations
  • SAD may be associated with SM
  • Holding unrealistically high standards
  • They learn to perform avoidance and safety behaviors to avoid disasters
  • Treatment: CBT, D-Cycloserine
• Reactive Attachment Disorder


  • Disorder manifest in similar fashion between the ages of 9 months and 5 years
  • Less is known about the clinical presentation of reactive attachment disorder in children, and diagnosis should be made with caution in children older than 5 yrs
  • Experienced history of severe social neglect
  • Show social communicative functioning comparable to their overall level of intellectual functioning
  • Show lack of preferred attachment despite having attained a developmental age of at least 9 months
• Disinhibited Social Engagement Disorder


  • Described from the second year of life through adolescence among children raised in institutional settings, and even into young adulthood
  • Can be distinguished from ADHD by not showing difficulties in attention or hyperactivity
• Posttraumatic Stress Disorder (PTSD)

  • Someone experiences trauma and developed disorder
  • The greater the vulnerability, the more likely we are to develop PTSD
  • Higher intelligence predicted decreased exposure to these types of traumatic events
  • If you have a strong supportive group of people around you, it is much less likely you develop PTSD after trauma
  • Heightened activity in the HPA axis
  • Treatment: Catharsis, Imaginal Exposure
  • In non-western groups, avoidance is less commonly observed, whereas in eastern groups somatic symptoms are more common
  • An adjustment disorder is also diagnosed when the symptom pattern of PTSD occurs in response to a stressor that does not meet PTSD criterion A
  • Requires that trauma exposure precede the onset or exacerbation of pertinent symptoms
  • Disruptions in the individual's attention and concentration can be attributable to alertness to danger and exaggerated startle responses to reminders of the trauma
• Acute Stress Disorder


  • Cannot be diagnosed until 3 days after a traumatic event
  • PD will only be diagnosed if panic attacks are unexpected and there is anxiety about the future attacks
  • If the symptoms persists for more than 1 month and meet the criteria for PTSD, then diagnosis will be changed to PTSD
  • Psychological Debriefing - form of crisis intervention that has victims of trauma talk extensively about their feelings and reactions within the days of critical incident
• Adjustment Disorder


  • Begins within 3 months of onset of a stressor
  • If symptoms persist beyond 6 months after the stressor or its consequences have ceased, the diagnosis will no longer apply
  • May sometimes be diagnosed instead of bereavement if bereavement is judged to be out of proportion to what would be expected or significantly impairs self-care and interpersonal relations
• Prolonged Grief Disorder


  • Focused on feelings of loss and separation from a loved one rather than reflecting generalized low mood
  • Involves distress from a deceased person
• PTSD


  Psychological Debriefing – form of crisis intervention that has victims of trauma talk extensively about their feelings and reactions within the days of critical incident
• Adjustment Disorder


  • Begins within 3 months of onset of a stressor
  • If symptoms persist beyond 6 months after the stressor or its consequences have ceased, the diagnosis will no longer apply
  • May sometimes be diagnosed instead of bereavement if bereavement is judged to be out of proportion to what would be expected or significantly impairs self-care and interpersonal relations
• Prolonged Grief Disorder


  • Focused on feelings of loss and separation from a loved one rather than reflecting generalized low mood
  • Involves distress from a deceased person
• Obsessive-Compulsive Disorder
• Obsessions


  Intrusive and mostly nonsensical thoughts, images, or urges that the individual tries to resist or eliminate
• Compulsions


  Thoughts or actions used to suppress the obsessions and provide relief
• 4 Major Types of Obsessions

  • Symmetry
  • Forbidden Thoughts or actions (Aggressive/Sexual/Religious)
  • Cleaning/Contamination
  • Hoarding
• It is also common for tic disorder to co-occur in patients with OCD
• Tendency to develop anxiety over having additional compulsive thoughts


  May have generalized biological and psychological precursors as anxiety in general
• Onset after the age 35 is unusual but does occur
• Obsessions of OCD


  Usually do not involve real-life concerns and can include one, irrational, or magical content
• In BDD and Trichotillomania, the compulsive behavior is limited to hair pulling in absence of obsessions
• Hypothesis 1: Early experiences taught them that some thoughts are dangerous and unacceptable


  Because terrible things they are thinking might happen and they would be responsible
• When children come to fear their own id impulses

  They use ego defense mechanisms to lessen anxiety
• Some children experience intense rage and shame

  As a result of negative toilet-training experience during the Anal Stage
• People with OCD have intrusive thoughts more often than other people
• Thought-Action Fusion


  • Clients with OCD equate thoughts with specific actions or activity represented by the thoughts
  • Caused by attitudes of excessive responsibility and resulting guilt developed during childhood, when even a bad thought is associated with evil intent