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Transcript of Family Therapy and Mental Health University of Guelph Open Learning and Educational Support.
Family Therapy and Mental Health
University of Guelph
Open Learning and Educational Support
Today: sadness and worry
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Review
Comments from last class Questions about assignments Areas not covered
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Presentation
Depression - Andrew and Dulcie
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Ordinary People
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Depressive Disorders
Disruptive mood dysregulation disorder Major depressive disorder Persistent depressive disorder Premenstrual dysphoric disorder Substance/medication-induced dd DD due to another medical condition Other specified DD Unspecified DD
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Disruptive Mood Dysregulation Disorder
To reduce overdiagnosis and treatment of bipolar disorder in children
Persistent irritability Frequent episodes of extreme behavioural
dyscontrol Up to age 12 Children of this pattern typically develop
unipolar depression or anxiety as adults, not bipolar disorder
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Major Depressive Disorder
At least two weeks’ duration Clear-cut changes in affect, cognition, and
neurovegetative functions Inter-episode remissions Bereavement is no longer excluded
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Persistent Depressive Disorder
At least 2 years in adults or 1 in children New in DSM-5 Combines chronic major depression and
dysthymia (DSM-IV)
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Premenstrual Dysphoric Disorder
Was in an appendix of DSM-IV Now in the main part of DSM-5 Specific and treatment-responsive form of
depressive disorder that begins after ovulation and remits after menses
Marked impairment of functioning
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Drugs and Medical Conditions
Substances of abuse Prescribed medications Medical conditions
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The Depression Map
A Holistic Approach to Understanding and Treating
Depression
The Depression Map(Randy J. Paterson, 2002)
Multi-causal No “one size fits all” Match strategies with cause & nature for
individual Understand how parts interact/effect each
other
The Depression Map(Randy J. Paterson, 2002)
The Depression Map(Randy J. Paterson, 2002)
Physiology Illness, disease, hormonal & metabolic disorders,
medication, alcohol/drugs, environmental toxins, nutritional deficiencies, sleep disorders, childbirth
Behaviour Diet, exercise, sleep, caffeine, sunlight, avoid
drugs/alcohol, having fun
The Depression Map(Randy J. Paterson, 2002)
Thinking Thought records, cognitive distortions,
attributional biases, perfectionism, worry, challenging negative thoughts, core beliefs
Emotion Stress, understanding & managing mood Fear, anger, guilt & shame
Current life situation Finding balance, goal setting, problem solving
The Depression Map(Randy J. Paterson, 2002)
Social setting Deepening current relationships Reviving old relationships Starting new friendships Social balance Being assertive Managing child care
The Depression Map(Randy J. Paterson, 2002)
Finding meaning Meaning inventory, welcoming the crisis,
spirituality, connecting to a larger cause Prevention
Managing stress Emergency action plan
Treatment
Treat the mood directly with antidepressant medication (or better music)
Treat the thinking with therapy
Medications for Anxiety and Depression
Improve the function of endogenous norepinephrine, serotonin and dopamine (neurotransmitters associated with mood)
Medications
Serotonin-Specific Reuptake Inhibitors (SSRI’s) 2-4 weeks response time suicide risk in children Generally much safer than TCA’s or MAOI’s
(below)
Medications
Heterocyclic (Tricyclic) Antidepressants (TCA’s) Amitriptyline, imipramine are examples 3-6 weeks response time Overdose very dangerous
Medications
Monoamine Oxidase Inhibitors (MAOI’s) Inhibit monoamine oxidase, so monoamines last
longer High blood pressure side effect ( tyramine)
Special diet 3-8 weeks’ response (must start at low dose) Overdose can be fatal E.g. Nardil, ENSAM, Parnate
Therapy
Behavioural (do pleasant or rewarding activities) Social skills (reduce social isolation) Cognitive (change thoughts, images,
interpretations) Interpersonal
Which works better?
Treatment of Depression Collaborative Research Program (1989) Historic multisite coordinated study 250 patients Randomly assigned
Interpersonal psychotherapy (IPT) Cognitive-Behavioural Therapy (CBT) Imipramine (tricyclic antidepressant) Placebo
TDCRP results
“no evidence of greater effectiveness of one of the psychotherapies as compared with the other and no evidence that either of the psychotherapies was significantly less effective than the standard reference treatment”
Severely depressed: imipramine>IPT>CBT>placebo Elkin et al, 1989, p. 980
Which therapy works best?
Why will almost anyone tell you that CBT is the “best practice” for treatment of depression if IPT>CBT?
See also Duncan and Miller (2000) The Heroic Client
Why is medication the treatment of choice for depression?
Depression
Segal 2002 Prevalence worldwide
17% -20% meet some criteria 10% major depression Twice as common in women
Suicide rate In recurrent depression: 15%
Recurrence
Defined as at least two episodes of major depression with a non-depressed period in between
About 20% of “first timers” will relapse Overall average rate of recurrence: 50% Two or more episodes: 80% risk Each recurrence worsens the disease
Relapse Prevention
Treat a major depressive episode with either medication or therapy (work equally well)
Stop treatment when the depressive episode is over
Who relapses?
Segal 2002, p. 24
Preventing Relapse
Therapy or medication appear to treat depression equally well (medication slightly better for severe depression)
Risk of relapse is significantly higher without therapy
The studies were done with cognitive behavioural therapy
The Power of Therapy After recovery from a depressive episode, all
subjects had “normal” thinking Introduce any stressful or traumatic event –
all people become sad, with concomitant cognitive triad (bad self, bad world, bad future)
Cognitive therapy seems to help people stay well after depression
Does it make them think better?
Mood affects thinking After depressive episode, thinking returns to
normal
Further studies
Induce a sad mood (country music) Thinking becomes distorted
People who ruminate on their thoughts (what’s wrong with me that my wife left me, stole my truck and ran over my dog?) stay depressed
People who distract themselves and move on, recover
Decentering of Thoughts from Self
Segal 2002 The essential ingredient in Cognitive Therapy
is not the content of the therapy, but the process of decentering
I have thoughts instead of I am my thoughts
Objectification of thoughts, or decentering of the self from thinking
CBT vs. other therapies
Self psychology is a form of decentering Interpersonal therapy works better than CBT Family therapy, narrative therapy, solution-
focused therapy – almost any form of therapy that encourages externalizing of problems or objective examination of thinking, ought to protect people from depression
Family Therapy for Depression
Gupta 2005 Bidirectional effects Marital stress depression
parenting problems
Family Therapy and Depression
Gupta 2005 Depression -> marital conflict
Individual and marital therapy both effective in treating depression and improving relationship
Marital conflict -> depression Marital therapy effectively treats both the
depression and the relationship Individual therapy makes the relationship worse
Treatment
Behavioural Marital Therapy BMT or BFT Conjoint marital IPT (IPT – CM) Parenting interventions (Barkley)
Suicide Stats
Approximately 4000 Canadians commit suicide each year; about 11/day
The World Health Organization estimates as many as 20 suicide attempts for every suicide death
Men are 4x more likely than women to complete suicide (lethal means)
Suicide Stats
Hospitalization rate for attempted suicide among females is highest aged 15 to 19
Among teens, girls are more likely than boys to have suicidal thoughts (8.4% vs. 4.6%)
Almost half of those admitted to hospital for attempted suicide have a major mental health issue
6 Steps to Suicide Intervention
1. Engage engage the person in conversation, listen,
empathize with feelings, be understanding, be honest and genuine
2. Identify identify warning signs
3. Inquire ask the person directly, “Are you having thoughts
of suicide?”
6 Steps to Suicide Intervention
4. Estimate have they attempted before? do they have a plan? (where, when, how) what supports do they have?
5. Contract negotiate a ‘no-suicide contract’, be specific about follow-up and what to do if they feel suicidal again, identify supports and resources with them
6. Follow through follow through on plans agreed upon
Cognitive Behavioural
Therapy (CBT)
Treatment Interventions for Depression
Origins of CBT
Epictetus, Greek Stoic philosopher (c.55 – c.135):
“Men are disturbed not by things, but by the view which they take of them.”
Origins of CBT
Alfred Adler, Austrian psychologist, 1870-1937:
“I am convinced that a person’s behaviour springs from his ideas.”
Development of CBT
Major influences: Albert Ellis, RET, mid-1950s, ABC model of
emotions Aaron Beck, Cognitive Therapy, 1960’s Don Meichenbaum, CBM, effective with children David Burns, popularized CBT with Feeling Good Marsha Linehan, DBT, integrates CBT with
mindfulness, effective w/BPD
CBT: General Principles
Present-oriented Structured Active Directed toward:
Solving current problems Modifying dysfunctional thinking and behaviour
Negative Cognitive Triad(A. Beck, 1963)
Look for negative beliefs about:SelfWorldFuture
Negative Explanatory Style for Bad Events (M. Seligman, 1991)
Internal vs. ExternalStable/Permanent vs. TemporaryGlobal vs. Specific
Cognitive Distortions(Burns, 1980)
1. All-or-Nothing Thinking
2. Overgeneralization
3. Mental Filter
4. Disqualifying the positive
5. Jumping to conclusions1. Mind reading
2. The fortune teller error
Cognitive Distortions(Burns, 1980)
6. Magnification and minimization
7. Emotional reasoning
8. Should statements
9. Labeling and mislabeling
10. Personalization
Triple-Column Technique (Burns, 1980)
1. Identify automatic thoughts2. Identify cognitive distortion
related to automatic thought3. Challenge distortion by writing a
rational response
Questions to Help Formulate a Rational Response
What is the evidence that the automatic thought is true/not true?
Is there an alternative explanation? What is the worst that could happen? How
likely is that? Would I live through it? What’s the best that could happen? What’s the most realistic outcome?
Questions to Help Formulate a Rational Response
What is the effect of my believing the automatic thought?
If my best friend was in this situation and had this thought, what would I tell him/her?
(the best-friend technique)
What are “Core Beliefs”?
Central ideas about self An absolute statement that seems
unchangeable (e.g. I’m unlovable) Formed early in life Act as a “fliter” Generally involve themes of helplessness or
unlovability Risk factors for future episodes
Identifying Core Beliefs
Find a general theme in negative automatic thoughts
Find underlying meaning of automatic thoughts by asking “what does this say about (me, others, or the world)?” (the downward arrow)
Challenging Core Beliefs
Make a list of evidence that a core belief is not 100% true
Test the belief with experiments Identify and strengthen alternative core
beliefs (e.g. affirmations) Historical tests of negative and alternative
core beliefs
For More Info. on CBT for Depression see:
Feeling Good by David Burns (1980)Mind Over Mood by Dennis
Greenberger & Christine Padesky (1995)
Cognitive Therapy of Depression by Beck, Rush, Shaw & Emery (1979)
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Presentation
Anxiety/OCD/Trauma - Inge and Heather
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Break
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What About Bob?
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Anxiety Disorders
Fear: emotional response to real or perceived imminent threat
Anxiety: anticipation of future threat Fear
Autonomic arousal: fight or flight Thoughts of immediate danger Escape Behaviours
Anxiety Muscle tension Vigilance Avoidant Behaviours
Developmentally Normal Fears
Age Normal Fear
Birth- 6 Months Loud noises, loss of physical support, rapid position changes, rapidly approaching other objects
7-12 Months Strangers, looming objects, unexpected objects or unfamiliar people
1-5 Year Strangers, storms, animals, dark, separation from parents, objects, machines loud noises, the toilet
6-12 Year Supernatural, bodily injury, disease, burglars, failure, criticism, punishment
12-18 Performance in school, peer scrutiny, appearance, performance
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Developmentally Abnormal Fears
Separation Anxiety Disorder Excessive distress about separation Excessive worry about losing attachment figure
including by an untoward event Reluctance to go out Reluctance about being alone Refusal to sleep w/o attachment figure Nightmares on the theme of separation Physical symptoms
4 weeks (children), 6 months (adults) 68
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Selective Mutism
Failure to speak in specific social situations Interferes with education or occupation At least 1 month Not attributable to not knowing the language Not better explained by a communication or
other (autism, schizophrenia) disorder
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Specific Phobia
Fear or anxiety about a specific object or situation
The object/situation almost always provokes fear/anxiety
Actively avoided or endured with intense fear/anxiety
Out of proportion to actual danger 6 months or more
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Social Anxiety Disorder
Social situations, exposed to possible scrutiny by others in peer settings
Fear of negative evaluation, including fear of showing anxiety symptoms
Almost always provoked Avoided or endured Out of proportion Six months or more
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Panic Disorder
Abrupt surge of intense fear with four of Palpitations Sweat Trembling Shortness of breath Choking Chest discomfort Nausea Dizziness Chills Tingling Derealization/depersonalization Fear of losing control Fear of dying
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Panic Disorder, continued
At least one attack followed by at least one month of one or both of Worrying about additional panic attacks Maladaptive behaviour to avoid panic attacks
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Panic Attack Specifier
Panic Attack as above, without the worry or avoidant behaviour
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Agoraphobia
Marked fear or anxiety about two or more: Using public transportation Being in open spaces Being in enclosed spaces Standing in line or being in a crowd Being outside of the home alone
Thoughts that escape might be difficult or embarrassing situation might occur
Situation(s) almost always provoke fear/anxiety Avoidance, companion, or extreme discomfort Out of proportion to the situation Six months or more
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Generalized Anxiety Disorder
Excessive anxiety and worry, more days than not, for at least 6 months, about a number of events or activities
Difficult to control Three or more:
Restlessness Fatigue Difficulty concentrating/mind going blank Irritability Muscle tension Sleep disturbance
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Substance/Medication-Induced Anxiety Disorder
Panic or anxiety Evidence
The symptoms started after substance use or withdrawal
The substance can produce anxiety Not better explained by another anxiety
disorder Not exclusively during delirium
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Anxiety Disorder due to Another Medical Condition
Panic or Anxiety Evidence that it is the direct effect of another
medical condition Not better explained by another mental
disorder Not exclusively during the course of delirium
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Anxiety Disorders - Prevalence
From: The Anxious Brain, M. Wehrenberg & S. Prinz, 2007: Nearly 26% of adult Americans suffer from
anxiety in a given year: 6.8% Social Anxiety Disorder 3.1% Generalized Anxiety Disorder 2.7% Panic Disorder
Anxiety Disorders - Comorbidities
Panic disorder: 25% also have GAD 15-30% also have SAD 10-20% also have specific phobia 8-10% also have OCD
50% with PD and GAD also have depression
SAD – Addressing Physiology
Rule out medical conditions e.g. heart, thyroid, hormone, hypoglycemia, adrenal fatigue
Teach diaphragmatic breathing and progressive muscle relaxation
Teach mindfulness skills “Three deep breaths and good preparation”
SAD – Medications
More use of PRNs with SAD than others Need for in vivo practice
Beta blockers: Propranolol (Inderal) & Atenolol (Tenormin)
Benzopiazepines: Clonazepam & Alprazolam MAOIs: Phenelzine SSRIs: Prozac
SAD – Addressing Behaviour
In Vivo exposure Assess social skill deficits Social skills training for specific fears,
assertiveness, anger and conflict management Systematic desensitization or EMDR
List every feared situation, rank from 0-100, imagery + coping skills
Create hierarchy for in vivo exposure then practice
SAD – Working with Families
Family members either push too hard or back off completely
Help them to find balance, matched with clients skill and developmental level
Remember that negative experiences reinforce fears
Help client negotiate practice with family Help family manage their own anxiety
Panic Disorder
Assessment &
Treatment
Panic Disorder(C. Padesky, 2011)
Catastrophic misinterpretation of physical and mental sensations
Seems to come out of nowhere → avoidance Panic attack ≠ panic disorder
Rule out medical conditions For PD to develop:
Vigilance for sensations Avoid situations that evoke sensations Use of safety behaviours
Panic Disorder(C. Padesky, 2011)
Assessment Choose recent, specific attack Identify sensations then review in detail Thoughts & images What was the worst thing that could have
happened? Use their words What would’ve happened if you couldn’t get out?
Panic Disorder(C. Padesky, 2011)
Hypothetical model:
trigger → sensations → automatic
thoughts → emotions → sensations →
focus on sensations → interpretation
of sensations → catastrophic
misinterpretation → PANIC
Panic Disorder(C. Padesky, 2011)
Treatment Need to induce sensations (“take the fear out of
panic”) Alternative explanation for sensations Differentiate between uncomfortable vs. fatal Medication may be contra-indicated re. therapy Do the induction, no safety behaviours, continue
until anxiety goes down Less than 10% relapse after 2 yrs.
Panic Disorder(C. Padesky, 2011)
Guidelines for Interoceptive Exposure Practices should be planned, structured,
predictable Pace can be gradual Subtle avoidance strategies should not be used Ritual prevention Use SUDS to rate fear throughout practice Practices should be repeated frequently Fighting Fear vs. Allowing Fear to Happen
Panic Disorder(C. Padesky, 2011)
Symptom Induction Exercises Shake head from side to side for 30 sec. Hold breath for as long as possible Breathe through a straw for 2 min. Overbreathe (hyperventilate) for 60 sec. Spin in a swivel chair for 30 sec. Tense every muscle in your body for 1 min. Jog on the spot for 2 min. Stare at a light for 2 min. Stare at someone’s mouth while they talk for 3 min.
Panic Disorder(C. Padesky, 2011)
Steps for Interoceptive Exposure
1. Present the rationale.
2. Assess for medical problems that might
affect the safety of certain exercises.
3. Conduct symptom induction testing.
4. Assign interoceptive exposure practices.
5. Combine with situational exposure.
Panic Disorder(C. Padesky, 2011)
Usually a narrow band of thoughts for PD No need for thought records, etc.
Focus more on sensations Treatment: 4 – 8 sessions, 12 at the most PD w/agoraphobia: 16 to 30 sessions
Systematic Desensitization
Create a hierarchy of exposure From easiest to hardest Usually begins with imagery Pair images with relaxation techniques
Exposure Procedure1. Enter the situation
2. Retreat only if anxiety is “out of control”
3. Recover, then continue
Exposure Therapy
What promotes success: Cooperation of your partner or spouse Willingness to tolerate some discomfort Ability to handle the initial symptoms of panic Ability to handle setbacks Willingness to practice regularly
GAD – Reid Wilson, 2009
PD is the easiest to treat, with the best outcome, whereas GAD is the hardest to treat
Worry about at least two of the following: Minor things – 91% Family/home – 79% Financial – 50% Work/school – 43% Illness/health/injury – 14%
GAD – Reid Wilson, 2009
It’s not the content of the worry, it’s the process that is problematic: They worry in order to try and prevent what they
are worrying about (to stay safe) Chronic worry leads to procrastination Becomes a self-perpetuating problem Nervous system is always on guard to threat and
they don’t know what it’s like to be relaxed
GAD – Treatment(R. Wilson, 2009)
“If it’s worth worrying about, it’s worth problem solving!” Teach them problem solving skills Help them make a decision w/reasonable risk and
follow through (e.g. cost/benefit analysis) Learn how to tolerate consequences/uncertainty Distinguish ‘signals’ from ‘noise’ Catch episodes and intervene early Mindfulness (present focused)
GAD – Treatment(R. Wilson, 2009)
Train in multiple relaxation techniques e.g. biofeedback, breathing, progressive muscle
relaxation, meditation, yoga, guided imagery Help them recognize the absence of relaxation as
a cue for skills Keep a worry log Cognitive restructuring Designate worry times – ‘worry free zones’
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Lunch
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As Good As It Gets
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Obsessive-Compulsive Disorder
Assessment &
Treatment
Obsessive-Compulsive Disorder(M. Antony, 2010)
Unwanted, repetitive thoughts, images or urges (obsessions)
Repetitive behaviours that occur in response to an obsession, to reduce anxiety (compulsions)
Causes significant distress or impairment Yale-Brown Obsessive-Compulsive Scale
Reduction ≥ 35% is considered success
Obsessive-Compulsive Disorder(M. Antony, 2010)
Obsessions: Contamination Doubting (forgetting) Aggressive Accidentally harming others Religious Sexual
Obsessive-Compulsive Disorder(M. Antony, 2010)
Compulsions Washing, cleaning Checking Repeating actions Repeating words, phrases, or prayers Counting Symmetry or exactness
Not just behaviours, can be thoughts too
Obsessive-Compulsive Disorder(M. Antony, 2010)
Other features Avoid feared situations Varying levels of insight (poor insight = worse
prognosis) Thought-action fusion (thought is as bad as
action) Magical thinking Inflated sense of responsibility (↑guilt) Thought suppression & rituals maintain problem
Obsessive-Compulsive Disorder(M. Antony, 2010)
Targets for treatment Compulsive rituals Avoidance of feared situations Cognitive avoidance and thought suppression Compulsions and safety behaviours Requests for reassurance Alcohol or drug use
Obsessive-Compulsive Disorder(M. Antony, 2010)
Exposure & Ritual Prevention (ERP) Considered “gold standard” psychological
treatment for OCD Between 63 – 83% participants who complete
gain some benefit Benefits are maintained over long-term Exposure isn’t enough, have to prevent rituals too Metaphor:
“Every time you do the compulsion, you’re putting gas in the car”
Obsessive-Compulsive Disorder(M. Antony, 2010)
Sample hierarchyItem Fear
Visit a cancer ward in a hospital 100
Shake hands with a person who has cancer 90
Talk to someone who has cancer 75
Eat in a hospital cafeteria 70
Walk through the halls of a hospital 60
Stand in front of a hospital 50
Read a library book about cancer 40
Talk to someone about cancer 25
Obsessive-Compulsive Disorder(M. Antony, 2010)
Imaginal exposure With clients who fear images, thoughts,
memories, or other mental stimuli Can involve mental exposure, exposure to verbal
descriptions, or written exposure Imagery should be multi-sensory Record sessions and listen to them for homework
Measure success by doing, not feeling (may be uncomfortable)
Obsessive-Compulsive Disorder(M. Antony, 2010)
If preventing rituals is impossible Eliminate certain rituals first (based on location,
time of day, ritual content) Delay the ritual Shorten the ritual Do the ritual differently (e.g. in a different order,
more quickly)
Obsessive-Compulsive Disorder(M. Antony, 2010)
Cognitive features of OCD Beliefs about responsibility Overestimating probability and severity of danger Overimportance of thoughts Control of thoughts Desire for certainty Consequences of anxiety Fear of positive experiences Perfectionism
Obsessive-Compulsive Disorder(M. Antony, 2010)
Cognitive strategies Thought records Countering probability overestimations Countering catastrophic thinking Responsibility pie chart (Mind Over Mood) Challenge meta-cognitions (vs. intrusive
thoughts) e.g. thinking about X means that I will do it
Best-friend technique (perspective taking) Cost-benefit analysis
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Treatment
Support Discuss the event Educate regarding coping mechanisms
(relaxation, diet, exercise, etc) e.g. CISM handout
Medications Therapies
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Medications
Imipramine - effective treatment of panic Amitriptyline - chronic pain, PTSD SSRIs, MAOIs, anticonvulsants, propranolol Xanax (but may introduce or exacerbate
substance-abuse disorder) in general, the drugs help with depression,
anxiety and hyperarousal but not with avoidance, denial and
emotional numbing Kaplan and Sadock 1998
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Break
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The Fisher King
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Trauma
Reactive Attachment Disorder Child rarely seeks comfort when distressed Minimal social contact, limited positive affect,
unexplained irritability, sadness, fear A pattern of extremes of insufficient care
Disinhibited Social Engagement Disorder Child is too friendly with unfamiliar adults Not just impulsive but socially disinhibited A pattern of extremes of insufficient care
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Posttraumatic Stress Disorder
Exposure to actual or threatened death direct experience witnessing hearing about it (new) repeated or extreme exposure to the details (e.g.
collecting body parts, hearing stories of child abuse) Intrusion symptoms, one or more
Recurrent, involuntary, intrusive, distressing memories Dreams Flashbacks (dissociative reactions) Distress from exposure to cues
Psychological, physiological 120
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PTSD, continued
Avoidance Memories, thoughts, feelings People, places, conversations, activities
Negative changes in thought and mood Amnesia Persistent and exaggerated negative beliefs Persistent distortions about cause Persistent negative emotional state Decreased interest in activities Detachment Inability to experience positive emotions
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PTSD, continued
Alterations in arousal Irritable/angry Reckless/self-destructive Hypervigilance Exaggerated startle response Problems concentrating Sleep disturbanc
Duration > 1 month With or w/o dissociative symptoms
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Acute Stress Disorder Exposure to actual or threatened death Nine or more:
intrusive memories distressing dreams dissociative reactions psychological distress/physiological reaction negative mood altered sense of reality amnesia avoiding thoughts avoiding reminders sleep disturbance irritable mood hypervigilance concentration startle
3 days to 1 month (PTSD lite)123
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Adjustment Disorders
Response to an identifiable stressor within 3 months
One or both Marked distress out of proportion Significant impairment
Not attributable to another mental disorder Not normal bereavement Resolves within 6 months of stressor ending
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Next Class Here again next week Sex, Drugs and Food
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