Anxiety Sensitivity Dimensions and Prediction of Fearful

Psychological Models I

PSYC 4500: Introduction to Clinical Psychology

Brett Deacon, Ph.D.

September 7, 2010

From Last Class

• Essential features of science

• Essential features of pseudoscience

• Relevance to clinical psychology

Mental Health in the News

• NY Times Article: “Child’s Ordeal Shows Risks of Psychosis Drugs for Young” http://www.nytimes.com/2010/09/02/business/02kids.html?_r=1&adxnnl=1&ref=general&src=me&adxnnlx=1283871663-/dgdgNop+ysBTDDVqGKEww

http://www.nytimes.com/2010/09/02/business/02kids.html?_r=1&adxnnl=1&ref=general&src=me&adxnnlx=1283871663-/dgdgNop+ysBTDDVqGKEww



Side Effects of Antipsychotics

• Marked weight gain/obesity

• Diabetes

• Hypertension and cardiovascular problems

• Tardive dyskenesia – involuntary movements of tongue, face, mouth, or jaw; usually irreversible• Prevalence: 32% after 5 years, 57% by 15

years, 68% by 25 years (Glazer et al., 1993)

• Deactivation syndrome: “disinterest, indifference, diminished concern, blunting, lack of spontaneity, reduced emotional activity, reduced motivation and will, apathy in the extreme”

Psychiatry and Anti-Psychotics

• Top-selling drug class

• From 1993 to 2002, antipsychotic use in people < 21 years increased 600% (now over 1 million prescriptions in US)

• Vast majority of prescriptions are off-label

Off-Label Prescribing

• One antipsychotic (Risperdal) is FDA approved for children ages > 5 who have autism and aggressive behavior, self-injury, tantrums, or severe mood swings

• Most children who take an antipsychotic do not received any other mental health services, including an assessment or psychotherapy

• Children who received antipsychotics were more likely to be male and have pervasive developmental disorder, mental retardation, ADHD, or disruptive behavior disorder http://www.ncbi.nlm.nih.gov/pubmed/20215922

• Among adults in the VA system, 60% who take antipsychotics do not have a diagnosis for which these drugs are approved (41.8% PTSD, 39.5% MDD, 20.0% anxiety disorder) http://www.ncbi.nlm.nih.gov/pubmed/19723731

http://www.ncbi.nlm.nih.gov/pubmed/20215922


Off-Label Prescribing• Off-label marketing

• Illegal but common practice

• Example: Eli Lilly recently paid massive settlement to US government for illegal off-label marketing of Zyprexa, the best-selling antipsychotic• FDA approved for schizophrenia and bipolar• Illegally marketed for dementia, Alzheimer’s,

agitation, aggression, hostility, depression, sleep problems

Economics of Off-Label Prescribing• From the US Justice Dept.http://www.dodig.mil/IGInformation/IGInformationReleases/EliLillyPressRelease.pdf:• “Eli Lilly knew that significant weight gain and obesity were adverse side

effects of Zyprexa and that weight gain and obesity were factors in causing hyperglycemia and diabetes.”

• “Lilly instructed the sales force to recommend Zyprexa for all adult patients with behavioral symptoms like agitation, aggression, hostility, mood and sleep disturbances, and depression.”

• “Eli Lilly's management created marketing materials promoting Zyprexa for off-label uses, trained its sales force to disregard the law, and directed its sales personnel to promote Zyprexa for off-label uses. Anticipating the possibility of resistance from primary care physicians to prescribing Zyprexa, defendant Eli Lilly specifically trained its sales representatives on how to respond to doctors' concerns about off-label uses of Zyprexa, and how to continue to promote Zyprexa for off-label conditions. Eli Lilly retained medical professionals to speak to doctors during peer-to-peer sessions about off-label uses of Zyprexa. When promoting Zyprexa to health care providers, Lilly emphasized that the weight gain side effect of the drug was a therapeutic benefit for patients who had trouble maintaining their weight.”

http://www.dodig.mil/IGInformation/IGInformationReleases/EliLillyPressRelease.pdf

Economics of Off-Label Prescribing

• Cost of Lilly’s record settlement: $1.415 billion

• 2008 Zyprexa sales: $4.696 billion

• 2007 Zyprexa sales: $4.761 billion

Psychotropic Polypharmacy

• Most (60%) psychiatry patients now receive 2 or more medications http://www.ncbi.nlm.nih.gov/pubmed/20048220

• One-third of patients receive 3 or more medications

• Vast majority of polypharmacy is off-label and of unknown safety and efficacy

• Major new trend in psychiatry: adding an antipsychotic or “mood stabilizer” to other medications

• About 10% of those taking an antidepressant also have a prescription antipsychotic


Announcements

• Sona pretest is open

• Next response paper is due a week from today

• France, C. M., Lysaker, P. H., & Robinson, R. P. (2007). The “chemical imbalance” explanation for depression: Origins, lay endorsement, and clinical implications. Professional Psychology: Research and Practice, 38, 411-420.

Questions for France et al. (2007) article; Response paper due Tuesday 9/14

• 1. The United States is one of 2 countries in the world to allow direct-to-consumer marketing of prescription drugs. How do you think this practice affects the beliefs and behaviors of persons living in the United States?

• 2. Look at the percentage of participants who endorsed “agree” or “undecided” to questions 3, 4, and 5 in Table 4 on page 417. Why do you suppose so many people endorsed these questions?

• 3. Describe two ways in which depressed clients who believe they suffer from a chemical imbalance might pose a challenge for providers of psychotherapy.

Announcements

• Exam #1 is next Thursday

Chapter 3:

Psychological Models in

Clinical Psychology

Models in Clinical Psychology

• Theoretical model – simplified pattern that shows how something might work

• “Science is built of facts the way a house is built of bricks, but an accumulation of facts is no more science than a pile of bricks is a house.” -Henri Poincare


• How models help in clinical psychology…• 1. Observe the experience/symptoms of a problem

• 2. Develop a theory about what causes and/or maintains the problem that might explain these observations

• 3. Gather scientific evidence to test the theory

• 4. If the theorized causes/maintaining factors are scientifically supported, develop treatment strategies that directly target them

• 5. Evaluate the effectiveness of these strategies in clinical trials


• Nearly all empirically supported psychological treatments were developed via this process

• Examples:• Cognitive therapy for depression• Behavioral activation for depression• Interpersonal therapy for depression


• Contrast this process with the development of pseudoscientific therapies

• 1. Observe the experience/symptoms of a problem

• 2. Develop a theory about what causes and/or maintains the problem that might explain these observations

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• 3. Gather scientific evidence to test the theory

• 4. If the theorized causes/maintaining factors are scientifically supported, develop treatment strategies that directly target them

• 5. Evaluate the effectiveness of these strategies in clinical trials


• Models are not always helpful. Why?

• 1. They may be incomplete

• Example: What causes depression? • Cognitive factors – cognitive therapy• Behavioral factors – behavioral activation• Interpersonal factors – interpersonal therapy• Biological factors – medication or

electroconvulsive therapy or transcranial magnetic stimulation


• 2. They may be wrong.

• Actual quotes from medical charts:• “From a psychodynamic perspective, he could be using his

OCD as a shield against other psychological conflicts or fears regarding dating, education, and career.” -psychiatry resident

• “In any case, Prozac did help him a long time ago and theoretically, his brain may have reverted back to the state in which it was responsive to Prozac, so we decided to go back on Prozac.” -psychiatry resident


• 3. They may be pseudoscientific, thereby failing to advance knowledge.

• Example:• Psychodynamic theory of panic disorder• Explanation for importance of eye movements

in ENDR


• 4. They may lead to ineffective or harmful treatment

• 5. They may cause harm in other ways

• Example: The “schizophrenogenic mother” idea that schizophrenia was caused by mothers who displayed rejecting behavior to their children, imperviousness to the feelings of others, and rigid moralism concerning sex and fear of intimacy

Psychoanalytic and Humanistic Models

• Development and influence on contemporary mental health practice

• Popular ideas: • Problems are symbolic, treatment must

uncover the hidden meaning of symptoms• The therapeutic relationship is necessary

and sufficient for overcoming problems

• FiLCHeRS analysis: problems with falsifiability, comprehensiveness, honesty, sufficiency

Therapy Training Across Disciplines (Weissman et al., 2006)

The Behavioral Model

• Arose in reaction to psychoanalytic model

• Disagreement with the “deeper meaning” of symptoms

• Rejection of immeasurable concepts as speculative and nonscientific

• Emphasis on experimentally demonstrable principles of conditioning and learning

Classical Conditioning

• First demonstrated by Ivan Pavlov (1927)

• Process by which a neutral stimulus acquires

the power to elicit a response by being

repeatedly paired with an unconditioned

stimulus


How classically conditioned responses are acquired:

1. An unconditioned stimulus (meat) automatically elicits

an unconditioned response (salivation)

2. A neutral stimulus (bell) is repeatedly paired with the

unconditioned stimulus (meat)

3. Eventually, the neutral stimulus (bell) becomes a

conditioned stimulus that has the power to elicit the

response (now called a conditioned response)


• Unconditioned stimulus = meat

• Unconditioned response = salivation to meat

• Conditioned stimulus = bell

• Conditioned response = salivation to bell

Pavlov showed that just about any stimulus could

evoke salivation in dogs if it was repeatedly paired with

the presentation of food.


• Everyday examples of classical conditioning:

• Opening food container for your pet

• Many product advertisements • http://www.youtube.com/watch?v=7Sz56mtQB1M

• http://www.youtube.com/watch?v=lSmNTqZ3wV4

• Feeling afraid when watching “Jaws”• http://www.usu.edu/psycho101/lectures/chp4learnin

g/jaws.wav

http://www.youtube.com/watch?v=7Sz56mtQB1M

http://www.youtube.com/watch?v=lSmNTqZ3wV4

http://www.usu.edu/psycho101/lectures/chp4learning/jaws.wav

http://www.usu.edu/psycho101/lectures/chp4learning/jaws.wav


• One-trial learning

• Taste aversions

• Stimulus generalization

• Example of Jenny, who almost choked and

subsequently came to fear shortness of

breath, tightness in throat, exercise, and

spicy foods


• How are conditioned responses extinguished?

• Repeatedly presenting the CS in the absence of the UCS

• Taste aversions (food without illness-causing bacteria)

• Invisible fence for dogs (boundary without shock)


• Exposure therapy: Habituation in anxiety upon prolonged exposure to fear cues

Classical Conditioning – Clinical Applications

While sitting in the passenger seat, Patti gets in an argument with her boyfriend and gestures toward him in anger. He loses control of the car on the highway, spins off the highway and almost runs into a bridge. He immediately accuses her of being crazy and trying to kill them both. Patti feels terrified and ashamed. She subsequently experiences high anxiety, intrusive recollections of the event, and occasional flashbacks when driving. She avoids driving whenever possible, particularly driving on highways, near bridges, and especially near the scene of the car accident. She avoids watching TV shows with car chases. She seeks therapy when her anxiety persists for weeks and starts to affect her quality of life.


• In Patti’s example, identify the:

• Unconditioned stimulus

• Unconditioned response

• Conditioned stimulus

• Conditioned response

• Examples of stimulus generalization


• How would you help Patti extinguish her conditioned fear?


Frank is obese. He often stops by McDonalds on his way to and from work for a large snack. At home, he eats in the living room in front of the TV, while watching TV in bed, while working in his garage, and while in the car. Any time he sits down to watch TV, works in his garage, or drives, he becomes hungry. To manage his hunger he has stashes of snack foods in each of these places.


• In Frank’s case, identify the:

• Unconditioned stimulus

• Unconditioned response

• Conditioned stimulus

• Conditioned response


How would you help Frank extinguish his

conditioned hunger?

Operant Conditioning

• Behavior is modified by its consequences

• Pleasurable consequences strengthen behavior• Positive reinforcement• Negative reinforcement

• Aversive consequences weaken behavior• Positive punishment• Negative punishment

Operant Conditioning – Clinical Applications

• Everyday examples of operant conditioning:

• A child learning to be potty trained by

receiving M&M’s as rewards

• Using an umbrella to avoid being wet

• Spanking a child for misbehaving

• Revoking a child’s TV privileges for

misbehaving


Howard has an anger problem and often loses his temper with his wife. He yells and threatens her if she doesn’t do exactly what he wants. After each explosive episode, Howard’s wife succumbs and he gets his way.


• What operant conditioning process is

maintaining Howard’s angry behavior?


maintaining his wife’s submissive behavior?

• How could you use operant conditioning to

help Howard reduce his angry behavior?


Irene is a recovering heroin addict with mild mental retardation. On the inpatient substance abuse unit, she often engages in a form of self-injurious behavior in which she stares at a staff member, smiles, strikes her ears with her hands, and repeats the word “no” while shaking her head. Staff members typically respond by approaching her, gently grabbing her hands, and reminding her that such behavior is not acceptable. The persistent nature of this behavior is a serious concern among staff members who don’t want Irene to hurt herself but are also concerned that she is manipulating them.



maintaining Irene’s self-injurious behavior?


maintaining the staff’s response to Irene’s self-

injurious behavior?

• How could you use operant conditioning to

change Irene’s behavior?

Operant and Classical Conditioning Can Work Together

A friend sent Ken pornographic pictures over the internet. Looking at the pictures made Ken sexually aroused and Ken masturbated to orgasm while looking at them and sitting in front of the computer. The next day, Ken found himself sexually aroused and he went to his computer, opened the pornographic images, and again masturbated. This happened several times over the course of a few days. Now, Ken is worried that he can’t stop thinking about sex since every time he sits down at his computer to try to work, he notices himself becoming sexually aroused, and he ends up looking at the sexual images and masturbating.

Operant and Classical Conditioning Can Work Together

• How is classical conditioning contributing to

Ken’s sexual arousal?

• How is operant conditioning contributing to

Ken’s sexual behavior?

Documents

Anxiety Sensitivity Dimensions and Prediction of Fearful