Chapter 5

Anxiety, Trauma- and Stress

Related, and Obsessive-
Compulsive and Related
Disorders
 Anxiety, Fear, and Panic

• Fear – The Present-Oriented Mood State

– Immediate fight or flight response to
danger or threat
– Involves abrupt activation of the
sympathetic nervous system
– Strong avoidance/escapist tendencies
– Marked negative affect
• Anxiety – The Future-Oriented Mood
State
– Apprehension about future danger or
misfortune
– Somatic symptoms of tension
– Characterized by marked negative
affect
• Anxiety and Fear are Normal Emotional
States
• Panic: Sudden, overwhelming fright or
terror
• Panic attack: abrupt experience of
intense fear, acute discomfort
– Physical symptoms: heart palpitations, chest
pains, shortness of breath, pins and needles,
dizzyness
 From Normal to Disordered Anxiety and
Fear

• Characteristics of Anxiety Disorders

– Pervasive and persistent symptoms of
anxiety and fear
– Involve excessive avoidance and
escape
– Cause clinically significant distress and
impairment
 The Phenomenology of Panic Attacks

• What is a Panic Attack?

– Abrupt experience of intense fear or
discomfort
– Several physical symptoms (e.g.,
breathlessness, chest pain)
– Fear as an alarm response
DSM-V: Panic Attack
Intense fear/discomfort with at least 4 of the following
symptoms, reaching peak in approx 10 minutes:
• Palpitation, pounding heart, incr heart rate
• Sweating
• Trembling/shaking
• Shortness of reath, smothering
• Feeling of choking
• Chest pain/discomfort
• Nausea, abdominal distress
• Feeling dizzy, faint, light-headed
• Derealization, depersonalization
• Feeling of losing control/going crazy
• Fear of dying
• Numbness/tingling sensations
• Chills/Hot flushes
 The Phenomenology of Panic Attacks
(continued)

• DSM-V Subtypes of Panic Attacks

– Expected [Situationally bound] (cued)
– Unexpected (uncued)
– [Situationally predisposed]
Causes of Anxiety and Related Disorders

Biological Contributions (NB: Not for assessment)

• Genetic Vulnerability – run in families

• Anxiety and brain circuits
– Depleted levels of GABA
• Activation of gene that promote
Corticotropin-releasing factor (CRF) >>
increased risk for panic disorder
 Biological Contributions to Anxiety and
Panic (continued)
• Deficiencies in Serotonin
• Limbic system associated with anxiety
• Behavioral inhibition System (BIS)
– Anxiety
• Fight/flight Systems (FFS)
– Fear
• Teenagers who smoke – found to be
prone to anxiety and panic
 Psychological Contributions

• Began with Freud

– Anxiety is a psychic reaction to fear
– Anxiety involves reactivation of an
infantile fear situation
Psychological Contributions (continued)

• Behavioral and Cognitive Views

– Invokes conditioning and cognitive
explanations
– Classical conditioning, modeling
– Anxiety and fear are learned responses
– Catastrophic thinking and appraisals
play a role
– Perception of lack of control
Psychological Contributions (continued)

• Early Childhood Contributions

– Experiences with uncontrollability and
unpredictability
• Social Contributions
– Stressful life events trigger
vulnerabilities (eg. divorce, death,
pressure to perform at school, illness,
injury, poverty/SES, etc.)
 An Integrated Model

• Integrative View – Triple Vulnerability Theory

– Generalized biological vulnerability/diathesis
– Generalized psychological vulnerability
– Specific psychological vulnerability (e.g.
fear of dogs from childhood)
 An Integrated Model (continued)

• Common Processes: The Problem of

Comorbidity (i.e. co-occurance)
– Comorbidity is common across the
anxiety disorders
– Major depression is the most common
secondary/additional diagnosis
 An Integrated Model (continued)

– About half (50%) of patients have two

or more secondary diagnoses
– Comorbidity Suggests
• Common factors
• A relation between anxiety and
depression
• Comorbidity also with Physical Disorders:
- thyroid disease, respiratory, gastro-
intestinal, arthritis, migraine headaches,
allergic conditions, cardiovascular disease,
hypertension

• Comorbidity with suicide

- 20% patients with panic d/o attempt
suicide ( Weissman et al.,)
- suicide ideation
- greater risk if depression is present
 The Anxiety Disorders: An Overview

• Generalized Anxiety Disorder

• Panic Disorder with and without
Agoraphobia (i.e. Panic Disorder &
Agoraphobia)
• Specific Phobias
• Social Phobia/Social Anxiety Disorder
 Traumatic- and Stress-Related
Disorders
• Posttraumatic Stress Disorder (PTSD)
• Adjustment Disorders
• Attachment Disorders
- reactive attachment disorder
- disinhibited social engagement
disorder
 Obsessive-Compulsive &
Related Disorders
• Obsessive-Compulsive Disorder
• Body Dysmorphic Disorder
• Hoarding Disorder
• Trichotillomania
• Excoriation
“Do you worry excessively about minor
things?”
 Generalized Anxiety Disorder (GAD)
Clinical Description (See Table 5.2, pg 130)
– Excessive uncontrollable anxious
apprehension and worry
– Coupled with strong, persistent anxiety &
worry
– Persists for 6 months or more
– Somatic symptoms differ from panic (e.g.,
muscle tension)
– Irritability, fatigue, restlessness, being on
edge, sleep disturbances
• Statistics
– Affects about 4% of the general population
– 3.1% in 1-year period; 5.7% in lifetime
– Females outnumber males approximately
2:1 ratio (2/3rd female)
– Onset is often gradual; beginning in early
adulthood; GAD is chronic
– Very prevalent among the elderly
– Tends to run in families
 GAD: Associated Features and Treatment
• Associated Features
– Persons with GAD have been called
“autonomic restrictors”
– Fail to process emotional component of
thoughts and images
• Treatment of GAD: Generally Weak
– Benzodiazapines – Often Prescribed
– Psychological interventions – Cognitive-
Behavioral Therapy
– Combined treatments – Acute vs. Long-
Term Outcomes
 Panic Disorder With and Without
Agoraphobia
• Overview and Defining Features
– Experience of unexpected panic attack
(i.e., a false alarm)
– Develop anxiety, worry, or fear about
another attack
– Many develop agoraphobia
 Panic Disorder With and Without
Agoraphobia (continued)
• Facts and Statistics
– Affects about 3.5% of the general
population
– Onset is often acute, beginning
between 25 and 29 years of age
– 75% of individuals with agoraphobia are
female
 Panic Disorder: Associated Features &
Treatment
• Associated Features
– Nocturnal panic attacks – 60% panic
during deep non-REM sleep
– Interoceptive/exteroceptive avoidance
• Medication Treatment
– Target serotonergic, noraadrenergic, and
GABA systems
– SSRIs (e.g., Prozac and Paxil) are
preferred drugs
– Relapse rates are high following
medication discontinuation
 Panic Disorder: Associated Features and
Treatment (continued)

• Psychological and Combined Treatments

– Cognitive-behavior therapies are
highly effective
– No evidence that combined treatment
produces better outcome
– Best long-term outcome is with
cognitive-behavior therapy alone
 Specific Phobias: An Overview

• Overview and Defining Features

– Extreme irrational fear of a specific
object or situation
– Persons will go to great lengths to avoid
phobic objects
– Most recognize that the fear and
avoidance are unreasonable
– Markedly interferes with one’s ability to
function
 Specific Phobias: An Overview (continued)

• Facts and Statistics

– Females are again over-represented
– Affects about 11% of the general
population
– Phobias tend to run a chronic course
Specific Phobias: Associated Features and Treatment

• Subtypes of Specific Phobia

– Blood-injection-injury phobia
– Situational phobia – Trains, planes,
automobiles, closed spaces
– Natural Environment phobia – Natural
events (e.g., heights, storms, water)
– Animal phobia – Animals and insects
– Separation Anxiety – Seen in children
Specific Phobias: Associated Features and
Treatment (continued)
• Causes of Phobias
– Biological and evolutionary vulnerability
– Three pathways -- Conditioning,
observational learning, information
• Psychological Treatments of Specific
Phobias
– Cognitive-behavior therapies are highly
effective – Exposure
 Social Phobia: An Overview

• Overview and Defining Features

– Extreme and irrational fear in
social/performance situations
– Markedly interferes with one’s ability to
function
– Often avoid social situations or endure
them with great distress
– Generalized subtype – Affects many
social situations
Subtype: performance anxiety
• Usually no difficulty with social interaction
• When have to do something in front of
other people, anxiety (stage fright)
• Anxiety: afraid they embarrass themselves
• Public speaking
• Eating in a restaurant
• Signing a document whilst other people are
watching
• Blushing, trembling, sweating
 Social Phobia: An Overview (continued)

• Facts and Statistics

– Affects about 13% of the general
population
– Prevalence is slightly greater in
females than males
– Onset is usually during adolescence
– Peak age of onset at about 15 years
 Social Phobia: Associated Features and
Treatment
• Causes
– Biological and evolutionary vulnerability
– Similar learning pathways as specific
phobias
• Psychological Treatment
– Cognitive-behavioral treatment
– Cognitive-behavior therapies are highly
effective
 Social Phobia: Associated Features and
Treatment (continued)

• Medication Treatment
– Tricyclic antidepressants and
monoamine oxidase inhibitors
– SSRIs Paxil, Zoloft, and Effexor – Are
FDA approved
– Relapse rates are high following
medication discontinuation
• Selective Mutism SM

• Re-aligned with the anxiety disorders

DSM5
• Rare childhood disorder
• Consistent failure to speak in specific
social situations despite speaking in others
Traumatic- and Stress-
Related Disorders
 Posttraumatic Stress
Disorder (PTSD):
• Enduring, distressing emotional disorder
• Follows after exposure to fear-inducing
threat
• Severe helplessness
 Posttraumatic Stress Disorder (PTSD):
An Overview
• Overview and Defining Features
– Main etiologic characteristics – Trauma
exposure and response
– Reexperiencing (e.g., memories,
nightmares, flashbacks)
– Avoidance
Posttraumatic Stress Disorder (PTSD): An
Overview (continued)

– Emotional numbing and interpersonal

problems
– Markedly interferes with one's ability to
function
– PTSD diagnosis – Only after 1 month
post-trauma
 Posttraumatic Stress Disorder (PTSD): An
Overview (continued)

• Statistics
– Combat and sexual assault are the most
common traumas
– About 7.8% of the general population
meet criteria for PTSD
• Subtypes and Associated Features of PTSD
– Acute – May be diagnosed 1-3 months post
trauma
– Chronic – Diagnosed after 3 months post
trauma
– Delayed onset – Onset 6 months or more
post trauma
– With Dissociative Symptoms –
depersonalization or derealization
– Acute stress disorder – PTSD immediately
post-trauma, ie. Within 1 month
 Posttraumatic Stress Disorder (PTSD):
Causes and Associated Features
(continued)

• Causes of PTSD
– Intensity of the trauma and one's reaction
to it (i.e., true alarm)
– Learn alarms -- Direct conditioning and
observational learning
– Biological vulnerability
– Uncontrollability and unpredictability
– Extent of social support, or lack thereof
post-trauma
 Posttraumatic Stress Disorder (PTSD):
Treatment
• Psychological Treatments
– Cognitive-behavior therapies (CBT) are
highly effective
– CBT may include graduated or massed
(e.g., flooding) imaginal exposure
– Aim of CBT for PTSD
 Attachment Disorders –
(read through only)

• Disturbed and developmentally

inappropriate behaviours in children
• Emerging before five years of age
• Child is unwilling/unable to form normal
attachment relationships with care giving
adults
• Reactive attachment disorder: seldom
allows an adult to take care
– Lack of responsiveness
– Limited positive affect
– Heightened emotionality (fear, sadness)

• Disinhibited social engagement disorder:

shows no inhibitions when approaching
adults
 Obsessive-Compulsive Disorder (OCD):
An Overview
• Overview and Defining Features
– Obsessions - Intrusive and nonsensical
thoughts, images, or urges
– Compulsions - Thoughts or actions to
neutralize thoughts
– Vicious cycle of obsessions and
compulsions
– Cleaning and washing or checking
rituals are common
 Obsessive-Compulsive Disorder (OCD):
Causes and Associated Features
• Statistics
– Affects about 2.6% of the general
population
– Most with OCD are female
– Onset is typically in early adolescence
or young adulthood
– OCD tends to be chronic
 Obsessive-Compulsive Disorder (OCD):
Causes and Associated Features
(continued)

• Causes of OCD
– Parallels the other anxiety disorders
– Early life experiences
– Learning that some thoughts are
dangerous/unacceptable
– Thought-action fusion -- The thought is
similar to the action
 Obsessive-Compulsive Disorder (OCD):
Treatment
• Medication Treatment
– Clomipramine and other SSRIs –
Benefit up to 60% of patients
– Relapse is common with medication
discontinuation
– Psychosurgery (cingulotomy) is used in
extreme cases
 Obsessive-Compulsive Disorder (OCD):
Treatment (continued)

• Psychological Treatment
– Cognitive-behavioral therapy is most
effective
– CBT involves exposure and response
prevention
– Combining CBT with medication -- No
better than CBT alone
Other Obsessive-Compulsive and
Related Disorders

• Body Dysmorphic Disorder

• Disruptive preoccupation with some

imagined defect in appearance (imagined
ugliness)
• Hoarding Disorder

• Excessive acquisition of things, difficulty

discarding anything and living with
excessive clutter under conditions best
characterised as gross disorganisation
• Trichotillomania (hair pulling disorder)
• Repetitive and compulsive hair pulling
resulting in significant and noticeable loss
of hair

• Excoriation (skin picking disorder)

• Repetitive and compulsive picking of the
skin leading to tissue damage
 Summary of the Anxiety Disorders

• Most Common Forms of Psychopathology

• From a Normal to a Disordered
Experience of Anxiety and Fear
– Triple Vulnerabilities – Bio-psycho-social
– Fear and anxiety – Non-dangerous
bodily or environmental cues
– Symptoms and avoidance – Significant
distress and impairment
 Summary of the Anxiety Disorders
(continued)

• Psychological Treatments are Generally

Superior in the Long-Term
– Similar treatments for different anxiety
disorders
– Suggests that anxiety-related disorders
share common processes