Anxiety Disorders and Obsessive-

Compulsive and Related

Disorders
 Overview of Anxiety Disorders
• Physical features -jumpiness, jitteriness, trembling or shaking, tightness in the pit
of the stomach or chest, heavy perspiration, sweaty palms, light headedness or
faintness, dryness in the mouth or throat, shortness of breath, heart pounding or
racing, cold fingers or limbs, and upset stomach or nausea, among other physical
symptoms.
• Behavioral features may include avoidance behavior, clinging or dependent
behavior, and agitated behavior.
• Cognitive features may include worry, a nagging sense of dread or apprehension
about the future, preoccupation with or keen awareness of bodily sensations, fear
of losing control, thinking the same disturbing thoughts over and over, jumbled or
confused thoughts, difficulty concentrating or focusing one’s thoughts, and thinking
that things are getting out of hand.
• The DSM recognizes the following major types of anxiety disorders:
panic disorder, phobic disorders, and generalized anxiety disorder.
• Several other disorders that were previously classified in the category
of anxiety disorders are placed in the DSM-5 in new diagnostic
categories with other disorders with which they share common
features.
 Panic Disorder
• characterized by repeated, unexpected panic attacks.
• Panic attacks : intense anxiety reactions that are accompanied by physical
symptoms such as a pounding heart; rapid respiration, shortness of breath, or
difficulty breathing; heavy perspiration; and weakness or dizziness.
• The attacks are accompanied by feelings of sheer terror and a sense of
imminent danger or impending doom and by an urge to escape the situation.
They are usually accompanied by thoughts of losing control, “going crazy,” or
dying.
• People often describe panic attacks as the worst experiences of their lives.
• Their coping abilities are overwhelmed. They may feel they must flee. If flight seems useless, they
may “freeze.”
• There is a tendency to cling to others for help or support.
• Some people with panic attacks fear going out alone.
• Recurring panic attacks may become so difficult to cope with that panic sufferers become suicidal.
• People with panic disorder may avoid activities related to their attacks, such as exercise or
venturing into places where attacks may occur or they fear may occur, or where they may be cut off
from their usual supports.
• Consequently, panic disorder can lead to agoraphobia—an excessive fear of being in public places in
which escape may be difficult or help unavailable (Berle et al., 2008).
• That said, panic disorder without accompanying agoraphobia is much more common than panic
disorder with agoraphobia (Grant et al., 2006b).
 Diagnosis
• The person must have experienced repeated, unexpected panic attacks, and at
least one of the attacks must have been followed by a period of at least one
month by either or both of the following features (Based on American
Psychiatric Association, 2013):
• a) Persistent fear of subsequent attacks or of the feared consequences of an
attack, such as losing control, having a heart attack, or going crazy
• b) Significant maladaptive change in behavior, such as limiting activities or
refusing to leave the house or venture into public for fear of having another
attack
• For a diagnosis of panic disorder to be made, there must be the
presence of recurrent panic attacks that begin unexpectedly—attacks
that are not triggered by specific objects or situations.
• They seem to come out of the blue. However, subtle physical
symptoms may precede an unexpected panic attack in the hour
preceding an attack, even though the person may not be aware of it
 Theoretical perspectives
• The prevailing view of panic disorder is that panic attacks involve a
combination of cognitive and biological factors, of misattributions
(misperceptions of underlying causes of changes in physical sensations) on the
one hand and physiological reactions on the other.
 BIOLOGICAL FACTORS
• The biological underpinnings of panic attacks may involve an unusually sensitive
internal alarm system involving parts of the brain, especially the limbic system and
frontal lobes, that normally become involved in responding to cues of threat or
danger.
• Psychiatrist Donald Klein (1994) proposed a variation of the alarm model called the
suffocation false alarm theory. He postulated that a defect in the brain’s respiratory
alarm system triggers a false alarm in response to minor cues of suffocation.
• In Klein’s model, small changes in the level of carbon dioxide in the blood, perhaps
resulting from hyperventilation, produce sensations of suffocation. These respiratory
sensations trigger the respiratory alarm, leading to a cascade of physical symptoms
associated with the classic panic attack: shortness of breath, smothering sensations,
dizziness, faintness, increased heart rate or palpitations, trembling, sensations of hot
or cold flashes, and feelings of nausea.
• The role of neurotransmitters, especially gamma-aminobutyric acid (GABA).
GABA is an inhibitory neurotransmitter, which means that it tones down excess
activity in the central nervous system and helps quell the body’s response to
stress.
• When the action of GABA is inadequate, neurons may fire excessively, possibly
bringing about seizures. In less dramatic cases, inadequate action of GABA may
heighten states of anxiety or nervous tension. People with panic disorder tend
to have low levels of GABA in some parts of the brain (Goddard et al., 2001)
 COGNITIVE FACTORS-role of anxiety sensitivity (AS)
• Anxiety sensitivity, or fear of fear itself, involves fear of one’s emotions and
bodily sensations getting out of control.
• When people with high levels of AS experience bodily signs of anxiety, such as
a racing heart or shortness of breath, they perceive these symptoms as signs
of dire consequences or even an impending catastrophe, such as a heart
attack.
TREATMENT
• Cognitive-behavioral therapists use a variety of techniques in treating panic
disorder, including coping skills development for handling panic attacks,
breathing retraining and relaxation training to reduce states of heightened
bodily arousal, and exposure to situations linked to panic attacks and bodily
cues associated with panicky symptoms. The therapist may help clients think
differently about changes in bodily cues, such as sensations of dizziness or
heart palpitations.
 Phobic Disorders
• In phobic disorders, however, the fear exceeds any reasonable appraisal of
danger.
• A curious thing about phobias is that they usually involve fears of the ordinary
events in life, such as taking an elevator or driving on a highway, not the
extraordinary.
 Types of Phobic Disorders
• The DSM recognizes three distinct phobic disorders: specific phobia, social
anxiety disorder (social phobia), and agoraphobia.
 Generalized Anxiety Disorder
• characterized by excessive anxiety and worry that is not limited to any one
object, situation, or activity.
• Normally, anxiety can be an adaptive response, a kind of built-in bodily warning
system to signal when something is threatening and requires immediate
attention.
• But for people with generalized anxiety disorder, anxiety becomes excessive,
becomes difficult to control, and is accompanied by physical symptoms such as
restlessness, jumpiness, and muscle tension.
• The central feature of GAD is excessive worry.
• They may worry about many things, including their health, their finances, the
well-being of their children, and their social relationships.
• They tend to worry about everyday, minor things, such as getting stuck in
traffic, and about unlikely future events, such as going bankrupt.
 Diagnostic Criteria
• A. Excessive anxiety and worry (apprehensive expectation), occurring more days
than not for at least 6 months, about a number of events or activities (such as work
or school performance).
• B. The individual finds it difficult to control the worry.
• C. The anxiety and worry are associated with three (or more) of the following six
symptoms (with at least some symptoms having been present for more days than
not for the past 6 months);
• 1. Restlessness or feeling keyed up or on edge.
• 2. Being easily fatigued.
• 3. Difficulty concentrating or mind going blank.
• 4. Irritability.
• 5. Muscle tension.
• 6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying
sleep).
 Diagnostic Criteria
• The anxiety, worry, or physical symptoms cause clinically significant distress
or impairment in social, occupational, or other important areas of
functioning.
• E. The disturbance is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical condition
(e.g., hyperthyroidism).
• F. The disturbance is not better explained by another mental disorder .
• They may avoid situations or events in which they expect that something
“bad” might happen. Or they might repeatedly seek reassurance from others
that everything is okay.
• To reach a diagnostic level, GAD needs to be associated with either marked
emotional distress or significant impairment in daily functioning.
• Children with generalized anxiety disorder tend to worry about academics,
athletics, and social aspects of school life.
• The emotional distress associated with GAD interferes significantly with the
person’s daily life. GAD frequently occurs together with other disorders,
including depression or other anxiety disorders such as agoraphobia and
obsessive–compulsive disorder.
• Related features include:
• restlessness; feeling tense, keyed up, or on edge;
• becoming easily fatigued; having difficulty concentrating or finding one’s mind
going blank;
• irritability; muscle tension; and disturbances of sleep, such as difficulty falling
asleep,
• Staying asleep, or having restless and unsatisfying sleep.
 Theoretical Perspectives
• Psychodynamic view: Generalized anxiety represents the threatened leakage
of unacceptable sexual or aggressive impulses or wishes into conscious
awareness.
• The person is aware of the anxiety but not its underlying source.
• The problem with speculating about the unconscious origins of anxiety is that
they lie beyond the reach of direct scientific tests.
• We cannot directly observe or measure unconscious impulses.
 learning perspective
• Generalization of anxiety across many situations.
• People concerned about broad life themes, such as finances, health, and family
matters, are likely to experience apprehension or worry in a variety of settings.
Anxiety would thus become connected with almost any environment or
situation.
• The cognitive perspective on GAD emphasizes the role of exaggerated or
distorted thoughts and beliefs, especially beliefs that underlie worry. People
with GAD tend to worry just about everything.
• They also tend to be overly attentive to threatening cues in the environment
(Amir et al., 2009), perceiving danger and calamitous consequences at every
turn.
• Consequently, they feel continually on edge, as their nervous systems respond
to the perception of threat or danger with activation of the sympathetic
nervous system, leading to increased states of bodily arousal and the
accompanying feelings of anxiety.
• The cognitive and biological perspectives converge in evidence showing
irregularities in the functioning of the amygdala in GAD patients and in its
connections to the brain’s thinking center, the prefrontal cortex (PFC)
Obsessive–Compulsive and Related Disorders
• Comprises of disorders that have in common-
• a pattern of compulsive or driven repetitive behaviors that are associated with
significant personal distress or impaired functioning in meeting demands of
daily life.
• In the following sections we focus on three major disorders in this category:
• obsessive–compulsive disorder,
• body dysmorphic disorder,
• hoarding disorder.
• Two other related disorders, trichotillomania (hair pulling disorder) and excoriation (skin
picking) disorder,
 Obsessive–Compulsive Disorder
• An obsession is a recurrent, persistent, and unwanted thought, urge, or mental
image that seems beyond the person’s ability to control.
• Obsessions can be potent and persistent enough to interfere with daily life and
can engender significant distress and anxiety.
• One may wonder endlessly whether one has locked the doors and shut the
windows, for example. One may be obsessed with the urge to do harm to one’s
spouse. One can have intrusive mental images or fantasies, such as the
recurrent fantasy of a young mother that her children had been run over by
traffic on the way home from school.
• Obsessions generally cause anxiety or distress, but not in all cases (APA, 2013).
• A compulsion is a repetitive behavior (e.g., hand washing or checking door
locks) or mental act (e.g., praying, repeating certain words, or counting) that
the person feels compelled or driven to perform (APA, 2013).
• Most compulsions fall into two categories: cleaning rituals and checking
rituals.
 Body Dysmorphic Disorder
• People with body dysmorphic disorder (BDD) are preoccupied with an
imagined or exaggerated physical defect in their appearance, such as skin
blemishes, wrinkling or swelling of the face, body moles or spots, or facial
swelling, causing them to feel they are ugly or even disfigured.
• They fear others will judge them negatively on the basis of their perceived
defect or flaw (Anson, Veale, & de Silva, 2012). They may spend hours
examining themselves in the mirror and go to extreme measures to correct
the perceived defect, even undergoing invasive or unpleasant medical
procedures, including unnecessary plastic surgery.
BDD is classified within the obsessive–compulsive spectrum because people
with the disorder often become obsessed with their perceived defect and often
feel compelled to check themselves in the mirror or engage in compulsive
behaviors aimed at fixing, covering, or modifying the perceived defect. In the
following case example of BDD, compulsive behavior takes the form of
repetitive grooming, washing, and styling hair.
Although BDD is believed to be relatively common, we don’t have specific data on the rates of the
disorder because many people with the disorder fail to seek help or try to keep their symptoms a
secret (Cororve & Gleaves, 2001; Phillips et al., 2006).
We should not underplay the emotional distress associated with BDD, as evidence shows high rates
of suicidal thinking and suicide attempts among people with the disorder (Buhlmann, Marques, &
Wilhelm, 2012; Phillips & Menard, 2006).
More encouraging is recent evidence based on a small group of people with BDD that showed most
patients eventually recovered, although it often took five years or longer (Bjornsson et al., 2011).
Intervention
• Exposure therapy with response prevention is often used in treating body dysmorphic disorder.
• Exposure can take the form of intentionally revealing the perceived defect in public, rather than
concealing it with makeup or clothing.
• Response prevention may involve efforts to avoid mirror checking (e.g., by covering mirrors at
home) and excessive grooming.
• ERP is generally combined with cognitive restructuring, in which therapists help clients
challenge their distorted beliefs about their physical appearance and evaluate them in light of
evidence (Phillips & Rogers, 2011).
 Hoarding Disorder
Compulsive hoarding, which is classified by DSM-5 as a newly recognized
disorder called hoarding disorder, is characterized by the accumulation of and
need to retain stacks of unnecessary and seemingly useless possessions, causing
personal distress or making it difficult to maintain a safe, habitable living space.
• People who hoard cling to their possessions, leading to conflicts with family
members and others who press them to discard the useless junk.
• Hoarding disorder has an important emotional component characterized by
the need to accumulate and retain possessions in order to feel a sense of
security.
• Despite the similarities to OCD, hoarding disorder in the DSM-5 is a distinct
disorder, not a subtype of OCD. There are important shades of difference
between hoarding disorder and OCD:
• obsessional thinking in hoarding disorder does not have the character of
intrusive, unwanted thoughts that it does in OCD. These thoughts in people
who hoard are typically experienced as a part of the normal stream of
thoughts.
• Another difference with OCD is that people who hoard typically experience
pleasure or enjoyment from collecting possessions and thinking about them,
which is unlike the anxiety associated with obsessional thinking in OCD.
• Underlying causal factors in hoarding behavior continue to be studied, but
recent research has probed its neurological basis.
• When thinking about acquiring and discarding possessions, people who hoard
show abnormal patterns of activation in parts of the brain involved in such
processes as decision making and self-regulation (Tolin et al., 2012).
• Further research along these lines may help us better understand the
difficulties people with this disorder face in making decisions to accumulate
objects and avoiding getting rid of them.
• Although hoarding has been difficult to treat, recent evidence shows promising
results from cognitive-behavior therapy focused on helping the person change
maladaptive beliefs about the need to accumulate and retain possessions and
working on strategies to discard them (Steketee et al., 2010).
The 55-year-old divorced man felt pressured to come for treatment because of complaints filed by neighbors who were concerned about a fire hazard (his house
was one of a series of attached row houses). A home visit revealed the extent of the problem. The rooms were filled with all kinds of useless objects, including
out-of-date food cans, piles of newspapers and magazines, and stacks of papers and even pieces of cloth. Most of the furniture was completely hidden by the
clutter. A narrow path around the clutter led to the bathroom and to the man’s bed. The kitchen was so cluttered that none of the appliances was accessible.
The man reported that he hadn’t used the kitchen in quite a while and routinely went out for his meals. There was a pervasive stale and dusty smell throughout
the house. When asked why he had kept all this stuff, he replied he felt fearful of discarding “important papers” and “things he might need.” But the observers
were at a loss to explain how any of these objects could be important or needed.
• Although BDD is believed to be relatively common, we don’t have specific data
• on the rates of the disorder because many people with the disorder fail to seek help or
• try to keep their symptoms a secret (Cororve & Gleaves, 2001; Phillips et al., 2006). We
• should not underplay the emotional distress associated with BDD, as evidence shows
• high rates of suicidal thinking and suicide attempts among people with the disorder
• (Buhlmann, Marques, & Wilhelm, 2012; Phillips & Menard, 2006). More encouraging
• is recent evidence based on a small group of people with BDD that showed most
• patients eventually recovered, although it often took five years or longer (Bjornsson
• et al., 2011). T / F
• Exposure therapy with response prevention is often used in treating body dysmorphic
• disorder. Exposure can take the form of intentionally revealing the perceived defect
• in public, rather than concealing it with makeup or clothing. Response prevention may
• involve efforts to avoid mirror checking (e.g., by covering mirrors at home) and excessive
• grooming. ERP is generally combined with cognitive restructuring, in which therapists
• help clients challenge their distorted beliefs about their physical appearance and evaluate
• them in light of evidence (Phillips & Rogers, 2011).
 Somatic Symptom and Related Disorders
• The word somatic derives from the Greek soma, meaning “body.”
• People with somatic symptom and related disorders (formerly called
somatoform disorders) may have physical (“somatic”) symptoms without an
identifiable physical cause or have excessive concerns about the nature or
meaning of their symptoms.
• The concept of somatic symptom and related disorders presumes that
psychological processes affect physical functioning. For example, some people
complain of problems in breathing or swallowing, or a “lump in the throat.”
Such problems can reflect overactivity of the sympathetic branch of the
autonomic nervous system, which might result from anxiety.
 Theoretical Perspectives
• Psychodynamic: obsessions represent leakage of unconscious urges or
impulses into consciousness, and compulsions are acts that help keep these
impulses repressed.
• Vulnerability to OCD is in part determined by genetic factors
• research evidence points to a possible role for a gene that works to tone down
the actions of a particular neurotransmitter, glutamate.