M&A

• People with SAD are invested in making a positive impression on others, but are insecure about ability to do so

• They hold negative beliefs about themselves and their ability to perform in social situations

• When in social situations people with SAD focus on themselves and see themselves as if they’re watching themselves on television

• Focusing on themselves doesn’t allow people with SAD to fully participate in the social situation

• People with SAD either avoid situations of use safety behaviors in feared situations

• Safety behaviors and avoidance do not allow the person to learn that fears may not actually come true

• Negative thinking about social situations occurs before, during and after

  exposure to the situation

hypothesize that SAD stems from a social tendency to interpret social situations as dangerous or threatening.

e.g. Beliefs: im stupid; Assumptions: if I make mistake everyone will laugh; Rule: My presentation should be perfect.

x

Diagnostic criteria:

1. Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g. at school) despite speaking in other situations

2. The disturbance interferes with educational or occupational achievement or with social communication

3. Thedurationofthedisturbanceisatleast1month(notlimitedtothefirstmonth of school)

4. Thefailureistospeakisnotattributabletoalackofknowledgeoforcomfortwith, the spoken language required in the social situation.

5. The disturbance is not better explained by a communication disorder (e.g childhood-onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia or another psychotic disorder.

x

People with GAD go through the day filled with exaggerated WORRY and TENSION
even though there is little or nothing to provoke it. Sometimes even just the thought of getting through the day produces anxiety.

People with GAD can’t seem to get rid of their concerns,
even though they usually realize that their anxiety is more intense than the situation warrants.

They anticipate disaster, and are overly concerned about health issues, money, family problems, or difficulties at school or work.

Lifetime prevalence ranging from 1.9-5.4% (Wittchen et al. 1994)

GAD develops gradually, and can begin at any point in the life cycle often lifelong history of anxiety often no clear age of oset (Barlow et al. 1986)

GAD affects 2x as many women as it does men (Wittchen et al. 1994)

There is some evidence that GAD may be one of the more common disorders in the elderly, 17% of elderly men and 21.5% of elderly women report severe anxiety symptoms (Himmelfarb and Murrell, 1994), however not clear if criteria for GAD are met

1. Biological factors:

Genetic predisposition:

- family and twin studies showed that genetic explain 30-40% of the variance of causative factors

Neurotransmitter systems:

- consistent Norepinephrine (= noradrenaline) overactivity in GAD alterations in GABA, serotonin system

Fear circuit

components of the fear circuit that may be of particular relevance to GAD include medial prefrontal cortex, amygdala, insular cortex
- irregularities in the functioning of the amygdala in GAD patients and its connection
to the prefrontal cortex (Etkin et al., 2009)

2. Psychological models to explain GAD

- Worry as cognitive avoidance model (Borovec)

- Worry as cognitive avoidance (Borcovec et al. 1994, 2004)

- Positive beliefs about worry (Marker & Aylward)

- Intolerance of uncertainty and its role in worry (Dugas et al. 1998)

- Information-Processing Biases associated with GAD

- Metaworry (Wells & Matthews)

- comprehensive model of factors assosiated with GAD

• During CBT therapists attempt to reduce low level of processing by having patients “worry out “ their negative emotions -> exposure therapy to help processing worry on a deeper level

• Although GAD mostly characterized by cognitive avoidance, behavioral avoidance of situations (e.g. social situations) is seen in over half of the individuals
  (Butler et al. 1987)

• CBT helps to reevaluate:
  - the positive benefits of worrying
  - interpretation biases of ambiguous stimuli - their intolerance of uncertainty
  - metaworry

• Most frequently studied, evidence-based, psychological strategies for treating GAD include:

-  Cognitive strategies (CBT)

-  Exposure-based strategies

-  Acceptance based strategies

• CBT has been shown to be very effective for the treatment of GAD, with long term effects

• Clinical improvement in 38-63% of individuals who complete treatment (Waters & Craske, 2005)
  -> this number not as high as CBT for other anxiety disorders
  (80% clinical improvement in panic disorder, Campbell & Brown, 2002)

• Adding of mindfulness components leads to improvement of existing CBT treatments, clinical improvement in 78% of individuals (Roemer et al.2008)

- studies with Benzos and Antideprs.

• Compared to placebo, benzodiazepines provide effective and rapid symptomatic relief (Galenberg et al. 2000)
  -> should not be used for more than 2-4 weeks
  -> side effects: dependency, sedation and increased risks of neonatal and infant mortility when used while breastfeeding or late pregnancy

• SSRI are the recommended treatment
  -> pharmacological treatments reduce physical symptoms rather than worry
  (Anderson & Palm, 2006)
  -> works also for co-morbidities
  -> long term efficacy of antidepressant with follow-up of years required
  ->efficacy over 6 months follow-up periods: greater remission rates than placebo at 6 months (69% vs. 42-46%)

! only very few studies compared effectiveness CBT with medication treatments for GAD

x

- is a chronic illness

A. Initial unexpected panic attacks (können aus Ruhezustand oder Angstzustand auftreten) with min. 4 symptoms (siehe DSM-5)...

B. one of these two during one panic attack for 1 month or longer:
- The subsequent persistent concern for future attacks
- Avoidance of perceived environmental triggers of the panic attack

• EMDR
• HYPNOTHERAPY (reported through several studies; BUT group studies with no controllgroup and dropouts)
• Pharmakotherapy IS NO TREATMENT OF CHOICE FOR SPECIFIC PHOBIA. Studies with Benzodiazephines did not show evidence of long-term reduction in anxiety or avoidance

• Blood-Injection-Injury phobia: treatment complicated by fainting applied tension-> tensing various muscle group during exposure

• Associated with increased risk for another anxiety or mood disorder

• 46% of people with SAD had another current psychological disorder and 72%

  lifetime diagnosis (Brown et al. 2001)

• Increased risk for panic disorder, specific phobias and depression, substance

  abuse (Chartier et al. 2003)

Mood disorders

• Pattern of illness due to an abnormal mood

• Almost every patient with mood disorder experiences depression at some point

• Many mood disorders will be diagnosed on the basis of a mood episode

• Period of time when a patient feels abnormal happy or sad

• Building blocks for codable mood disorders

• Most of the patients with mood disorders have one or more of these three episodes:

  • Major depressive episode (for at least 2 weeks depressed, feeling guilt, eating or sleeping problems etc.)
  • Manic episode (for at least 1 week patient feels elated, happy, hyperactive...Bad judgment leads to marked social or work impairment; often patients must be hospitalized.)
  • Hypomanic episode (briefer and less severe as manic episode)

• Major depressive disorder

• Persistent depressive disorder (dysthymia)

• Disruptive mood dysregulation disorder (<18 years)

• Premenstrual dysphoric disorder

• Depressive disorder due to another medical condition

• Substance/medication induced depressive disorder

• Other specified, or unspecified, depressive disorder

.

• Female sex (prevalenz in women 2 x higher then men; women different coping styles and rumination; hihger biological susceptibility; higner personal interdependence)
• Age (begin in adolescence, phases of transition)
• low socioeconomic status
• Marital status (separation)
• Family member with depression
• Somatic disease (chronic pain, thyroid disorders, cancer, cardiac diseases, AIDS..)
• Number of depressive episodes, degree of remission from first episode, age of beginning of first episode
• comorbidities

Major depressive disorder is a common and serious medical illness

• negatively affects feelings, thinking and behavior

• causes feelings of sadness and/or a loss of interest in activities once enjoyed

• can lead to a variety of emotional and physical problems

• can decrease a person’s ability to function at work / home

Sadness/Grief:

• painfull feel. come in waves, often mixed with positive memories of the decreased
• self-esteem is no affected

Depression:

• Mood and/or pleasure decreased for most of two weeks
• Feelings of worthlessness / self- loathing common

When both of them co-exist togehter, then grief is more severe and last longer.

BUT: despite the overlap, they are still different!!!

x

• Separation:depressiveandbipolardisorders

• Additionof3newcategoriesofdepressivedisorders (disruptive mood dysregulation disorder, persistent depressive disorder, and premenstrual dysphoric disorder)

• Numberofbipolardisordersisunchanged

• Entityofmooddisordersnototherwisespecifiedhasbeen replaced with unspecified bipolar disorder and unspecified depressive disorder

• Criteria forepisodesofmania,hypomaniaandmajor depressions are generally unchanged with a few important exeptions

Not included in the DSM-V are the following criteria:

• B. the symptoms do not meet criteria for a mixed episode coexistence within a major depressive episode of at least 3 manic

symptoms (not sufficient to meet for manic episode) is now aspecifier
• E. The symptoms are not better accounted for by bereavement

Behavioral:....

Cognitive: ....

Emotional

Social: ...

Physical

fertig stellen (S.45)

• One or more major depressive episodes

• No manic or hypomanic symptoms

• Sudden or gradual onset

• Episodes last between 6 to 9 months

• Full recovery less likely for co-morbid personality disorders, severe episodes, psychotic features

• Half of the patients having MDD, develop second episode

• At least two months or more between episodes to count as separate

• Symptoms remain similar between episodes

siehe DSM V

oneset, course, duration:

• Beginning in adolescence (5-19y)

• Mean age at onset (30 y)

• Mean start treatment (33.5 y)

• Elderly onset

• Course is variable

• Duration variable (6-13 months)

MDE Is one of the building blocks of mood disorders but not a codable diagnosis!!!

• Must meet 5 requirements:

1) a quality of depressed mood (loss interest/pleasure)

2) has existed for a minimum period of time

3) is accompanied by a required number of symptoms

4) has resulted in distress and disability

5) violates none of the listed exclusions