Models of Behavior

Theory drives Therapy

The example of Depression

• Symptoms of Depression

• Why is someone depressed?

• Situational?

• Due to Parenting?

• Due to biological deficits?

• Due to Interpersonal Problems?

• Due to thinking problems?

E.g. of Violence

• Why are some people violent

• Washington D.C. murders: Why did he kill?

• Psychopathology (Aspergers? Schizophrenia?)

• Is aggression a natural part of human nature?

• Biological Deficit?

Violence, cont.

• Is violence learned (Bandura=vicarious learning)

• Psychodynamic (violence=catharsis)

• Is Violence due to irrational, illogical ideas (cognitive)

Why use Theory

• Theory Provides a systematic way of examining behavior (road map)

• Contains certain elements:

• Parsimony

• Internal Consistency

• Testability

• Empirical Support

Challenge Question

• Think of your own mood level or anxiety level. What is your anxiety level on a 0-8 scale? What is your mood level? Why?

• Do you see your mood as linked to daily events?

• Do you see your mood as linked to current stressors?

• Do you see your mood linked to biology?

Panic

• Panic Attack vs. Panic Disorder

• Subsumed by the Anxiety Disorders (PTSD, GAD, SP, PD, OCD)

• Biological: Autonomic Activity

• Psychological: Stressors

• GAD as precursor

Szasz vs. Ellis

• debate

What is a cured patient?

• Case of Smoking Cessation

• Threats to blind in any study (what is blind?)

Breaking Down Panic

• Lang’s 3-system model of emotion:

Cognitive Behavioral Physio

I’m going to die Call E.R. HR, sweat

Panic Attack Scenario I: 1st a behavior

Run for the bus (behavior) HR increases (phsiological) “Something’s wrong with me” (cognitive) Further increase in HR, Sweat, Dizziness”I’m really a mess” Walk’s home (Behavior)”I can’t even go to work” (mood drops)

Panic Attack Scenario II: 1st a physiological event

Nausea from eating bad food (physio) “There is something wrong with me” (cognitive) HR, BP, sweat, dizziness, tingling (physio) “I’m seriously ill” (cognitive misinterpretation) Further exacerbation of physical sensations (physiological) ER visit or call to doctor for serious medical problem (behavior)

Tx follows 3-system analysis

• Enter each system

• Cognitive: Education about panic; cognitive therapy

• Behavior: Exposure to panic situations; avoid avoiding

• Physiological: BRT (Breathing Re-training), Deep Muscle Relaxation; Interoceptive Exposure

Delivery

• CBT delivered in 12 weekly sessions

• Follow-up important

• Compares well with meds (slightly more effective)

• Combined meds and CBT most effective

• Theoretical issues (e.g., attribution problems with meds)

CBT for Panic: Details

• Education: The Nature of Anxiety; The Biology of Anxiety; Common Myths (cardio disease, MVP, schizophrenia)

• Relaxation (BRT; Deep Muscle Relaxation)

• Cognitive therapy: a) for panic and b) for gen. anxiety

• De-catastropizing vs. Probability analysis

CBT Details (cont.)

• Interoceptive Exposure:

1. Review Concept

2. Ratings for Intensity of sensations 0-8

3. Ratings for Intensity of Anxiety 0-8

4. Repeat trials until extinction of anxiety

5. Need for Booster sessions

Challenge Question

• Tolerating anxiety related discomfort: Have we become a culture of worriers who can’t tolerate a bit of autonomic arousal? Or, are these legitimate problems?

OCD

• One of most debilitating of AD’s

• 1-3% prevalence

• Strong Biological Issue: Orbital prefrontal cortex and caudate nucleus shows abnormal activity

• These areas repaired by successful meds and Behavioral treatment

Other support for Bio Model

• Response to SSRI’s

• Marijuana increase OCD

• Encephalitis outbreaks (Robin Williams in Awakenings) related to increased OCD

• OCD vs. other medical illnesses (e.g., diabetes)

• OCD and Tourette’s• PANDAS http://en.wikipedia.org/wiki/PANDAS

More bio theories

• Mixed data on genetic studies

• One twin study shows 65% concordance rate but some studies show no elevation in 1st degree relatives

• Murphy et al (1997) and Swedo, et al (1997) showed that a genetic marker for rheumatic fever linked to increased childhood OCD

Randy Pauch’s final lecture

• http://video.stumbleupon.com/#p=ithct48cqw

OCD: Pt example

• Video clip

Treatment

• Exposure with Response Prevention

• Based on tension reduction model

• Systematic nature of treatment

• Use of sig. others as coaches

• Treatment effectiveness (80-90%)

• Meds tx (60-75%) with SSRI’s

• Combined treatment

Co-morbidity• Table 1: The Distribution of Symptom Scores of 910 Participants Meeting• Full Screen Criteria for OCD• Type I: THOSE WHO MET CRITERIA FOR OCD ONLY• Anxiety Problem N %• OCD only 65 7.1• Type II: OCD AND ONE ADDITIONAL ANXIETY PROBLEM• OCD + GAD 163 17.9• OCD + PD 16 1.8• OCD + PTSD 5 0.5• OCD + SP 19 2.1• Type III: OCD AND TWO ADDITIONAL ANXIETY PROBLEMS• OCD + SP + GAD 116 12.7• OCD + PD + GAD 145 15.9• OCD + GAD + PTSD 21 2.3• OCD + PD + SP 12 1.3• OCD + PD + PTSD 3 0.3• OCD + SP + PTSD 0 0.0• Type IV: OCD AND THREE ADDITIONAL ANXIETY PROBLEMS• OCD + PD + GAD + SP 200 22.0• OCD + PD + GAD + PTSD 38 4.2• OCD + GAD + SP + PTSD 20 2.2• OCD + PD + SP + PTSD 5 0.5• Type V: OCD AND FOUR ADDITIONAL ANXIETY PROBLEMS• OCD + PD + GAD + SP + PTSD 82 9.0• Key: OCD=Obsessive-Compulsive Disorder; GAD=Generalized Anxiety Disorder; PD=Panic Disorder; SP=Social Phobia; PTSD=Post-

Traumatic Stress Disorder

Ego Syntonic vs. Ego Dystonic

• Do you believe that your symptoms are senseless or not?

• Case of Sarah: Describe

• Other case examples (how do we treat?)

• Use of hierarchies

• Use of sig. others as coaches

• Avoid involvement with rituals

Tx implications for Comorbid OCD

• OCD/GAD- differentiating obsession from excessive worry (Cog. Therapy vs. thought stopping)

• OCD/panic differentiating OCD fear from panic fear (response blocking vs. cog. Therapy

• OCD plus PTSD (more difficult to tx?)

Challenge for OCD

Think of repetitive behaviors in your own life. What are they? What purpose do they serve? How would you go about bringing them under control?

Or, think of repetitive behaviors in a friend or loved one? Answer the same questions above.

OCD

• Note your own compulsions. How would you self-treat?

Tourette as Continuum?

• Multiple body and vocal tics

• Reduce stress, reduce tics