PSCY Essay

Anxiety, Obsessive-Compulsive, and Trauma- and Stressor-Related Disorders SSY 230: Lecture 7

Anxiety Disorders

The central defining feature of anxiety disorders is the experience of a chronic and intense feeling of anxiety in which people feel a sense of dread about what might happen to them in the future. The anxiety experienced by people with anxiety disorders causes them to have great difficulty functioning on a day-to-day basis. This feeling goes beyond the typical worries people have from time to time about performing their everyday activities at work or home, or in their interactions with other people.

People with anxiety disorders also experience fear, which is the emotional response to real or perceived imminent threat. Again, like the experience of anxiety, the sense of fear that people with these disorders have goes beyond ordinary or even rational concern over the possible dangers of the situations in which they find themselves.

People with anxiety disorders go to great lengths to avoid situations that provoke the emotional responses of anxiety and fear. When they are unable to do so, they will have difficulty performing jobs, enjoying leisure pursuits, or engaging in social activities with friends and families.

Anxiety Disorder Prevalence

Across all categories, anxiety disorders have a lifetime prevalence rate in the United States of 28.8 percent.

The percent of people reporting lifetime prevalence across all anxiety disorders peaks between the ages of 30 and 44, with a sharp drop off to 15.3 percent among people 60 years and older

The average age of onset across all anxiety disorders is

21.3 years of age, with ranges from 15 years and younger

to up to 39 years, depending on the nature of the

disorder.

Note the gender differences in the chart.

Separation Anxiety Disorder

Individuals with separation anxiety disorder have intense and inappropriate anxiety about leaving home or being left by their attachment figures, the people close to them in their lives. Children with this disorder may cling so closely to a parent they will not let the parent out of their sight. Adults who meet the criteria for this disorder have intense anxiety about being separated from the person to whom they are most emotionally attached.

Prior to the DSM-5, the condition of separation anxiety disorder was considered specific to children. However, recognizing that there are a significant number of adult-onset cases, DSM-5 lifted the disorder’s age restriction to make it diagnosis applicable to adults as well as children. Although the key features of the disorder can vary according to the individual’s age, always included is being excessively distressed when separated from the home or the attachment figure or even at the thought of such separation occurring.

Part of the anxiety people with the disorder experience is worry about harm befalling their attachment figure, such as him or her being kidnapped, a fear that can become extreme and irrational. This worry leads them to try to avoid spending any time apart or away from home, interfering with their ability to work or go to school. They need to sleep near their attachment figures and may have nightmares about separation. The prospect of separation may lead them to develop physical complaints such as headaches, stomachaches, or even nausea and vomiting.

Regardless of when the symptoms first become evident, people with this disorder were more likely to have suffered adversities during their childhood or traumatic events at some point in their lives. Females are more likely than males to experience separation anxiety disorder. People who develop this disorder are at greater risk of subsequently developing other anxiety disorders and depressive disorder (“internalizing” disorders) as well as ADHD and conduct disorder.

Theories of Separation Anxiety Disorder

Although twin studies supported the role of genetic contributions to this disorder, a novel children-of-twins study conducted by Swedish researchers suggested that anxiety is passed down from parents to children through environmental, rather than genetic, mechanisms. In other words, children with anxious parents learn to develop anxiety through modeling.

Sociocultural factors also play a role in predisposing certain individuals to developing separation anxiety disorder. The symptoms of the disorder seem to be more severe in countries that promote an individualistic, independent culture than in those with a more collectivist set of cultural norms. Remaining with attachment figures may seem more acceptable in collectivist cultures, so the behavior of individuals with separation anxiety disorder may not appear so out of the ordinary.

Trauma may also play a role in the development of separation anxiety disorder.

In the aftermath of the September 11 terrorist attacks in 2001, nearly 13

percent of New York City schoolchildren had a probable diagnosis of separation

anxiety disorder. It is possible that temperamental differences rooted in

biology cause some children to experience heightened reactivity in these kinds

of situations.

Treatment of Separation Anxiety Disorder

At present, the treatment literature does not include studies of adults, given that the condition was considered specific to childhood until DSM-5’s publication. For children, both behavioral and cognitive-behavioral therapies (CBT) seem to have the greatest promise. Behavioral techniques include systematic desensitization, prolonged exposure, and modeling. Contingency management and self-management are also useful in teaching the child to react more positively and competently to a fear-provoking situation.

Researchers investigating the effectiveness of this approach have developed a form of CBT that clinicians can administer in an intensive and time-limited manner, so children do not have to commit to weeks or months of therapy. In one version, girls with separation anxiety disorder attended a 1-week camp where they received intensive CBT in a group setting. The treatment included working with parents and their children in a combination of psychoeducation, cognitive restructuring, and relaxation training. Craft activities without the parents present took place at regularly scheduled times. At the end of the week, the children and their parents attended an awards ceremony. At that time, parents were also given training for follow-up during the weeks subsequent to camp. Relapse prevention training was also built into the final day’s activities to ensure that, should a bout of separation anxiety reoccur, parents and children did not revert completely to their pretreatment behavior.

Selective Mutism

Refusing to talk in specific situations is the core feature of selective mutism. Children with this disorder are capable of using normal language, but they become almost completely silent under certain circumstances, most commonly the classroom. Anxiety may be at the root of selective mutism given that children most typically show this behavior in school rather than at home.

Children with selective mutism seem to respond well to behavioral therapy. The clinician devises a hierarchy of desired responses, beginning by rewarding the child for making any utterances and then progressing through words and sentences, perhaps moving from the home to the clinic and eventually to the school. Another behavioral approach uses contingency management, in which children receive rewards if they engage in the desired behavior of speaking. Contingency management seems particularly well suited for use in the home by parents. Of the two methods, shaping plus exposure therapy seems to be more effective, but contingency management in the home can nevertheless serve as an important adjunct.

CBT is another method that produces improvement in children with selective mutism. An investigation of CBT’s effectiveness among children age 3 to 9 years showed high rates of improvement for children younger than 5 (78 percent) and less improvement for children 6 and older. The treatment, which was adapted for school settings, progressed through six levels, from speaking to the therapist with the parent present to ultimately speaking to other children with neither the therapist nor the parent present. Parents and teachers were instructed to use “defocused communication,” in which they minimize the direct pressure placed on the child to speak. CBT can have lasting benefits, as indicated in a follow-up showing the gains in these children persisting 5 years post-treatment.

Specific Phobias

A phobia is an irrational fear associated with a particular object or situation. It is common to have some fear of or at least a desire to avoid such objects as spiders or situations with enclosed spaces or heights. In a specific phobia, however, the fear or anxiety is so intense that it becomes incapacitating.

People with specific phobia go to great lengths to avoid the feared object or situation. If they can’t get away, they endure the situation but only with marked anxiety and discomfort. Like all anxiety disorders, a specific phobia induces significant distress. Moreover, it is not a fleeting condition but must be present for at least 6 months to justify a diagnosis.

Almost any object or situation, from the act of driving to syringes, can form the target of a phobia. However endless the list of possible specific phobias may be, they fall into four major categories: insects and animals, the natural environment (storms or fires), blood-injection-injury (seeing blood, having an invasive medical procedure), and engaging in activities in particular situations (riding an escalator, flying). A fifth category includes a variety of miscellaneous stimuli or situations such as fear of vomiting.

The two most common forms of specific phobia are fear of natural situations (particularly heights), and animal phobias.

Phobia Types

Insects and Animals

● Snakes

● Spiders

● Birds

● Dogs

The Natural

Environment

● Heights ● Water

● Storms

● Earthquakes

Blood-Injection-Injury

● Seeing blood ● Getting blood drawn

● Having an

invasive medical procedure

Situational

● Being in an enclosed space

● Driving

● Riding an escalator

Miscellaneous

● Vomiting ● Clowns

● Loud noises

Specific Phobias

Biological Theory and Treatment of Specific Phobias

There are many types of specific phobias, ranging from the common to the relatively obscure. However, the fact that they are grouped together suggests an underlying theme or element at the root of their cause and, potentially, their treatment.

Within the biological perspective, researchers believe the anxiety associated with specific phobias may relate to abnormalities in the anterior insular cortex. This area of the brain lies between the temporal and frontal lobes and is associated with emotion and self-awareness. The amygdala, which moderates the fear response, also seems to play a role in specific phobias, particularly those acquired through learning in which people associate a given stimulus with the emotion of fear.

Treatment of specific phobias following from the biological perspective focuses on symptom management. Clinicians operating from this perspective prescribe medications, primarily benzodiazepines, but only if their clients do not respond to other treatments. Unlike other forms of anxiety disorder, specific phobias are more circumscribed in nature and the situations are generally more easily avoided. Thus, clinicians would prescribe medications only when the specific phobia interferes with the individual’s ability to carry out ordinary activities to such a degree that he or she cannot function on a daily basis.

Behavioral Theory and Treatment of Specific Phobias

The behavioral approach to specific phobias emphasizes the conditioning that occurs when the individual learns to associate unpleasant physical sensations with a certain kind of stimulus or situation. Behaviorists assume there may be some adaptive value to having such reactions, because the situations may truly be ones we should fear, such as poisonous snakes. The symptoms become maladaptive, according to this view, as individuals begin to generalize an appropriate fear reaction to all stimuli in that category, including harmless ones.

According to the cognitive-behavioral view, individuals with specific phobias have overactive alarm systems for danger, and they perceive things as dangerous because they misinterpret harmless stimuli. For example, the mistaken perception of an object or a situation as uncontrollable, unpredictable, dangerous, or disgusting is correlated with feelings of vulnerability. These attributions might explain the common phobia of spiders, an insect about which people have many misconceptions and apprehensions. In blood-injection-injury phobia, in contrast, disgust and fear of contamination play a prominent role. People with phobias also tend to overestimate the likelihood of a dangerous outcome after becoming exposed to the feared stimulus.

Cognitive-behavioral treatment for specific phobia focuses on helping the client learn more adaptive ways of thinking about previously threatening situations and objects by challenging their irrational beliefs about the feared stimuli. For example, a therapist may show a young man with an elevator phobia that the disastrous consequences he believes will result from riding in an elevator are unrealistic and exaggerated. The client can also learn the technique of “talking to himself” while in this situation, telling himself that his fears are ridiculous, that nothing bad will really happen, and that he will soon reach his destination.

As illustrated in the following table, behavioral treatments vary according to the nature of the client’s exposure to the phobic stimulus (live or imaginal) and the degree of intensity with which the stimulus is confronted (immediate full

Graduated

Exposure

Imagery Systematic Desensitization

Immediate Full Exposure

Imaginal Flooding

exposure or exposure in graduated steps).

Live Graded in vivo In vivo flooding

Exposure Therapy

In exposure therapy, positive reinforcement is used to lead clients to substitute adaptive responses (relaxation) for maladaptive ones (fear or anxiety). The four methods of exposure therapy vary in the way this basic procedure is carried out

Systematic desensitization presents the client with progressively more anxiety-provoking images while at the same time the client is being trained to relax. The idea is that the client cannot feel both anxious and relaxed at the same time, and that over the course of treatment, anxiety will be completely replaced with relaxation.

In the behavioral technique called flooding, clients are totally immersed in the feared situation, where they feel the anxiety with full force. ● In vivo flooding exposes the client to the actual feared situation, such as the top floor of a tall building for a client who fears heights (In vivo flooding is probably the most stressful of any of the treatments described and therefore has a high dropout rate). ● Another variant of flooding is imaginal flooding, in which the clinician exposes the client virtually to the feared situation. ● An alternative is the graded in vivo method in which clients initially confront situations that cause only minor anxiety and then gradually progress toward those that cause greater anxiety. Often the therapist tries to be encouraging and to model the desired nonanxious response. (In treating a client who has a fear of enclosed spaces, the therapist could go with the client into smaller and smaller rooms. Seeing the therapist showing no signs of fear could lead the client to model the therapist’s response).

Virtual Reality Exposure Therapy

The most recently tested variant of exposure therapy uses virtual reality exposure therapy (VRET), in which clients become immersed in computer-generated environments that resemble the situations they fear.

Safer than in vivo therapy for obvious reasons and more realistic than imaginal methods, VRET would seem to be an ideal way to provide clients with experiences that can allow them to unlearn their fears.

It is quite likely that VRET will become increasingly used to treat specific phobias given the rapid growth in the availability of this form of technology.

Please create a discussion board thread giving an example of a specific phobia. Include what type of phobia it is (insect-animal,situational, etc.), and suggest a potential course of treatment.

Social Anxiety Disorder

The primary feature of social anxiety disorder is a fear of becoming humiliated or embarrassed in front of other people.

Extending beyond the ordinary concerns people may have about

looking foolish or making a mistake during a performance, this

disorder makes people anxious even at the prospect of eating or

drinking in front of others.

Thus, the fear is not of other people (it is not a phobia), but rather of

what other people may think of the individual. In DSM-IV-TR, the

disorder was referred to as social phobia; it was renamed in DSM-5

with “social phobia” in parentheses.

Social Anxiety Disorder

Biological Theory and Treatment of Social Anxiety Disorder

The biological underpinnings of social anxiety disorder may, some researchers believe, be related to partly heritable mechanisms. The intense anxiety experienced by an individual with social anxiety disorder, from this perspective, is essentially a form of intense shyness combined with the personality trait of neuroticism. These qualities in turn either cause or are caused by alterations in areas of the brain responsible for attention. Individuals with social anxiety disorder, according to this view, become excessively self-focused and therefore exaggerate the extent to which others look critically upon them.

Of the possible medications that can be used to treat social anxiety disorder, the selective serotonin or norepinephrine reuptake inhibitors (SSRIs and SNRIs) are regarded as having the greatest effectiveness. Other medications that may work as well have considerable drawbacks. Benzodiazepines have significant potential for abuse; moreover, they may actually interfere with treatment that includes psychological methods such as exposure to feared situations. MAOIs, which can also effectively manage social anxiety symptoms, have potentially dangerous side effects.

Cognitive Behavioral Theory and Treatment of Social Anxiety Disorder

Among psychological approaches, the cognitive-behavioral perspective regards people with social anxiety disorder as unable to gain a realistic view of how others really perceive them. As in other forms of cognitive-behavioral therapy, the clinician working from this perspective attempts to reframe the client’s thoughts in combination with real or imagined exposure.

Related to the cognitive-behavioral approach is the view of social anxiety disorder as reflecting a core fear of interacting with new people in new situations. Rather than viewing the various symptoms of the disorder as having independent origins, researchers working within this network model believe the specific fears (such as being unable to look new people in the eye or to take a test in front of others) may all be interrelated via a central connection to that core fear of strangers. Following this approach, therapy would attempt to treat the core set of fears, which would then have a cascade effect on the more peripheral symptoms.

Nevertheless, treatment of social anxiety disorder can be particularly challenging, because clients may tend to isolate themselves socially and therefore have fewer opportunities to expose themselves to challenging situations in the course of their daily lives. Their impaired social skills may then lead them to experience negative reactions from others, thus confirming their fears. Unfortunately, researchers attempting to use VRET find virtual scenarios less effective than in the treatment of specific phobias. Although virtual exposure may evoke similar responses as in vivo exposure to social situations, when it comes to reenacting those social situations in therapy, individuals need to be exposed to an actual audience.

For clients who do not respond to psychotherapy or medication, there are promising signs about the benefits of alternate methods, including motivational interviewing, acceptance and commitment therapy, and mindfulness/meditation. Their common element, also present in CBT, is the practice of stepping back from situations to identify and challenge automatic thoughts.

Panic Disorder

People with panic disorder experience periods of intense physical discomfort known as panic attacks.

During a panic attack, the individual feels overwhelmed by a range of highly unpleasant physical sensations. These can include respiratory distress (shortness of breath, hyperventilation, feeling of choking), autonomic disturbances (sweating, stomach distress, shaking or trembling, heart palpitations), and sensory abnormalities (dizziness, numbness, or tingling). During a panic attack, people may also feel that they are “going crazy” or losing control.

Having an occasional panic attack is not enough to justify a diagnosis of panic disorder. To meet the diagnostic criteria, the panic attacks have to occur on a repeated basis and be accompanied by fear of having another.

People with this disorder also might engage in avoidance behaviors, staying away from situations in which another panic attack might occur.

Panic attacks are somewhat common in that they are estimated to occur in 20 percent or more of adults; panic disorder has a much lower lifetime prevalence of between 3 and 5 percent.

Agoraphobia

In agoraphobia, the individual feels intense fear or anxiety triggered by real or anticipated exposure to situations such as using public transportation, being in an enclosed space such as a theater or an open space such as a parking lot, and being outside the home alone.

People with agoraphobia are fearful not of the situations themselves but of the possibility that they can’t get help or escape if they have panic-like symptoms or other embarrassing or incapacitating symptoms when in those situations.

Their fear or anxiety is out of proportion to the actual danger they might face. If they cannot avoid the situation, they become highly anxious and fearful, and to cope, they might require the presence of a companion.

As in other psychological disorders, these symptoms must persist over time (in this case, at least 6 months), cause considerable distress, and not be due to another psychological or medical disorder.

Theories and Treatment of Panic Disorder and Agoraphobia

Researchers studying biological contributions to panic disorder focus on norepinephrine, the neurotransmitter that helps prepare the body to react to stressful situations. Higher levels of norepinephrine can make the individual more likely to experience fear, anxiety, and panic. Serotonin may also play a role in increasing a person’s likelihood of developing panic disorder, as deficits in serotonin are linked to anxiety.

Furthermore, according to anxiety sensitivity theory, people who develop panic disorder have heightened responsiveness to the presence of carbon dioxide in the blood. Hence, they are more likely to panic due to the sensation that they are suffocating.

The most effective anti-anxiety medications for panic disorder and agoraphobia are benzodiazepines, which increase the availability of the inhibitory neurotransmitter GABA. However, because benzodiazepines can lead clients to become dependent on them or to abuse them, clinicians may prefer to prescribe SSRIs or SNRIs.

Theories and Treatment of Panic Disorder and Agoraphobia

From a classical conditioning perspective, panic disorder results from conditioned fear reactions in which the individual associates bodily sensations such as difficulty breathing with memories of the last panic attack, causing a full-blown panic attack to develop. The cognitive-behavioral model proposes that people with panic disorder, upon feeling the unpleasant sensations of the panic attack begin (loss of breath), believe it is unpredictable and uncontrollable and that they will not be able to stop it.

Adding to their desire to avoid the unpleasant emotions associated with these experiences, people with panic disorder and agoraphobia may also have personality traits that exacerbate their symptoms, including high levels of neuroticism and low levels of extraversion. Their tendency to ruminate, to prefer not to experience strong emotions, and to keep to themselves may serve to maintain their symptoms above and beyond whatever was their prior exposure to anxiety-provoking situations.

Relaxation training is one behavioral technique used to help clients gain control over the bodily reactions that occur in panic attacks. After training, the client should be able to relax the entire body when confronting a feared situation. Another approach focuses on breathing. The client is instructed to hyperventilate intentionally and then to begin slow breathing, a response that is incompatible with hyperventilation. Following this training, the client can begin the slow breathing at the first signs of hyperventilation. In addition to changing the response itself, this method allows clients to feel that they can exert voluntary control over the development of a panic attack. In the method known as panic-control therapy (PCT), the therapist combines breathing retraining, psychoeducation, and cognitive restructuring to help individuals recognize and ultimately control the bodily cues associated with panic attacks.

Generalized Anxiety Disorder

The key feature of generalized anxiety disorder is that, unlike the disorders you have learned about so far, it does not have a particular focus. People with generalized anxiety disorder feel anxious for much of the time, even though they may not be able to say exactly why they feel this way. In addition, they worry a great deal, apprehensively expecting the worst to happen to them.

Their symptoms span a range of physical and psychological experiences

including general restlessness, sleep disturbances, feelings of fatigue,

irritability, muscle tension, and trouble concentrating, to the point where

their mind goes blank.

There is no particular situation they can identify as lying at the root of

their anxiety, and they find it difficult to control their worrying.

There are differences between older and younger adults in the nature of

generalized anxiety disorder. Older individuals worry more about their

own health and family well-being, and young adults worry more about

their own future and the health of other people. Older adults also show

more sleep disturbances, are less likely to seek reassurance, and show

higher rates and severity of depression accompanying their anxiety.

Generalized Anxiety Disorder

Theories and Treatment of Generalized Anxiety Disorder

Biologically based theories of generalized anxiety disorder focus on disturbances in GABA, serotonergic, and noradrenergic systems. Support for the notion that there is a biological component to generalized anxiety disorder is the finding of an overlap in genetic vulnerability with the personality trait of neuroticism. In other words, people who are prone to developing this disorder have inherited an underlying neurotic personality style.

Cognitive-behavioral therapy builds on the assumption that the anxiety people with this disorder experience results from cognitive distortions in their interpretation of the minor inconveniences of life. Clinicians using this approach attempt to break the cycle of negative thoughts and worries by helping clients learn how to recognize anxious thoughts, to seek more rational alternatives to worrying, and to take action to test these alternatives. Once the cycle of worry has been broken, the individual can develop a sense of control over the worrying behavior and become better able to manage and reduce anxious thoughts when they threaten to become overwhelming.

Another compounding factor in generalized anxiety disorder may be the individual’s inability to tolerate uncertainty or ambiguity. The outcomes of many common situations in life are indeed ambiguous. People with this disorder seek to reduce uncertainty by trying to know exactly what will happen when, without taking into account the fact that it is not always possible to know the outcome of every situation. Cognitive-behavioral therapy can be of benefit in helping individuals with the disorder come to accept such ambiguities.

Cognitive-behavioral therapy is therefore considered the method of choice in treating individuals with generalized anxiety disorder, particularly because it avoids the potentially negative side effects of antianxiety medications. Researchers are continuing to explore variations in the basic cognitive-behavioral approach to give individuals a broader set of options. Acceptance and commitment therapy (ACT) is thought to have similar mechanisms to CBT and is gaining evidence as a stand-alone treatment for various anxiety disorders.

Obsessive Compulsive Disorder

An obsession is a recurrent and persistent thought, urge, or image that the individual experiences as intrusive and unwanted. Individuals try to ignore or suppress the obsession or to neutralize it by engaging in some other thought or action. The thought or action the person uses to try to neutralize the obsession is known as a compulsion, a repetitive behavior or mental act the person feels driven to carry out according to rigid rules. Compulsions need not, however, be paired with obsessions.

In obsessive-compulsive disorder (OCD), individuals experience either obsessions or compulsions to such an extent that they find it difficult to conduct their daily activities. As part of the disorder, they may experience significant distress or impairment in their ability to work and have a satisfying family or social life.

Obsessive Compulsive Disorder

The most common compulsions experienced by people with OCD are repeated behaviors such as washing and cleaning, counting items, putting items in order, checking, or requesting assurance. These compulsions may also take the form of mental rituals, such as counting up to a certain number every time the individual has an unwanted thought. Some individuals with OCD experience tics, which are uncontrollable motor movements such as twitches, vocalizations, and facial grimaces.

In general, there appear to be four major dimensions of the

symptoms of OCD. These are the needs for:

● Symmetry

● Order

● Cleanliness

● The saving of apparently useless items

Yale-Brown Obsessive-Compulsive Symptom Checklist Items

Aggressive obsessions

Contamination obsessions

Fear might harm self

Fear of blurting out obscenities

Fear will be responsible for something else terrible happening (e.g., fire, burglary)

Concerns or disgust with bodily waste or secretions (e.g., urine, feces, saliva)

Bothered by sticky substances or residues

Miscellaneous obsessions Fear of saying certain things

Lucky/unlucky numbers

Superstitious fears

Cleaning/washing compulsions Excessive or ritualized hand-washing

Excessive or ritualized showering, bathing, toothbrushing, grooming, or toilet

routine

Checking compulsions Checking locks, stove, appliances, etc.

Sexual obsessions Forbidden or perverse sexual thoughts, images, or impulses Sexual behavior toward others (aggressive)

Hoarding/saving obsessions Distinguish from hobbies and concern with objects of monetary or sentimental value

Checking that did not make mistake completing a task

Repeating rituals Rereading or rewriting

Need to repeat routine activities (e.g., in/out door, up/down from chair)

Religious obsessions Concerned with sacrilege and blasphemy Excess concern with right/wrong, morality

Counting compulsions +

Ordering/arranging compulsions

(Check for presence)

Obsession with need for symmetry or exactness Accompanied by magical thinking (e.g., concerned that another will have an accident unless things are in the right place)

Somatic obsessions Concern with illness or disease Excessive concern with body part or aspect of appearance (e.g.,

dysmorphophobia)

Hoarding/collecting compulsions Distinguish from hobbies and concern with objects of monetary or sentimental value

(e.g., carefully reads junk mail, sorts through garbage)

Miscellaneous compulsions Excessive list making

Need to tell, ask, or confess

Need to touch, tap, or rub

Rituals involving blinking or staring

Theories and Treatment of OCD

Given the prominent role in OCD of motor movements such as cleaning and ordering, the biological basis for the disorder has long been thought to originate in abnormalities in the basal ganglia, which are subcortical areas of the brain active in motor control. Further contributing to the motor symptoms was thought to be failure of the prefrontal cortex to inhibit unwanted thoughts, images, or urges. Brain scan evidence now supports these explanations, showing heightened levels of activity in the brain’s motor control centers of the basal ganglia and frontal lobes.

The most effective biological treatment for OCD is clomipramine (a tricyclic antidepressant) or an SSRI such as fluoxetine or sertraline. In extreme cases in which no other treatments provide symptom relief, people with OCD may be treated with psychosurgery. For example, deep-brain stimulation to areas active in motor control can help relieve symptoms by reducing the activity of the prefrontal cortex, which in turn may help reduce the frequency of obsessive-compulsive thoughts.

The cognitive-behavioral perspective on OCD proposes that maladaptive thought patterns contribute to the development and maintenance of OCD symptoms. Individuals with OCD may be primed to overreact to anxiety-producing events in their environment. Such priming may place OCD in a spectrum of so-called internalizing disorders that include other anxiety and mood disorders invoking a similar pattern of startle reactivity. For people with OCD, these experiences become transformed to disturbing images, which they then try to suppress or counteract by engaging in compulsive rituals. Complicating their symptoms are beliefs in the danger and meaning of their thoughts, or their

“metacognitions,” which lead people with OCD to worry, ruminate, and feel they must monitor their every thought. Additionally, people with OCD may be high in the personality trait of perfectionism, a component of neuroticism, that can be thought of as a cognitive vulnerability unique to this disorder.

Cognitive-behavioral therapy is currently regarded as the most effective treatment for OCD. In addition to reducing target symptoms, cognitive-behavioral therapy had beneficial effects on the individual’s everyday quality of life

Body Dysmorphic Disorder

People with body dysmorphic disorder (BDD) are preoccupied with the idea that a part of their body is ugly or defective. Their preoccupation goes far beyond the ordinary dissatisfaction many people feel about the size and shape of their body or appearance of a particular body part. People with BDD may check themselves constantly, groom themselves to an excessive degree, or constantly seek reassurance from others about how they look. They don’t necessarily see themselves as fat or excessively heavy, both of which are common concerns in Western cultures, but they may believe that their body build is too small or not muscular enough.

The DSM-5 reclassified BDD from its prior placement in the anxiety disorders to its current inclusion with obsessive-compulsive and related disorders. The main change was to include repetitive behaviors, such as checking the mirror or seeking reassurance, as part of the criteria, changes that seem to have improved diagnostic accuracy.

This modification of the Yale–Brown Obsessive-Compulsive Scale uses the following criteria to determine the severity of the client’s symptoms regarding the presumed body defect or defects:

1. Time occupied by thoughts about body defect

2. Interference due to thoughts about body defect

3. Distress associated with thoughts about body defect 4. Resistance against thoughts about body defect

5. Degree of control over thoughts about body defect

6. Time spent in activities related to body defect such as mirror checking, grooming, excessive exercise, camouflaging, picking at skin, asking others about defect

7. Interference due to activities related to body defect 8. Distress associated with activities related to body defect 9. Resistance against compulsions

10. Degree of control over compulsive behavior 11. Insight into the nature of excessive concern over defect 12. Avoidance of activities due to concern over defect

Body Dysmorphic Disorder

As many as 87 percent of women are dissatisfied with some aspect of their body’s appearance. Overall, however, at any one point in time, the prevalence of BDD is a much lower 2.5 percent of women and 2.2 percent of men. The most common areas that concern people with BDD differ by gender, with men more likely to be concerned with their body build and thinning hair, and women with their weight and hip size.

BDD is frequently accompanied by major depressive disorder, social anxiety disorder, obsessive-compulsive disorder, and eating disorders. Clients’ distress clearly can become intense. Completed suicides are 45 times more common among people with this disorder than in the

general U.S. population.

Treatment of Body Dysmorphic Disorder

Treatment of BDD from a biological perspective includes medications, particularly SSRIs, that can reduce the associated symptoms of depression and anxiety as well as the more obsessive symptoms of distress, bodily preoccupations, and compulsions. Once on SSRIs, people with BDD can experience improved quality of life and overall functioning and perhaps gain insight into their disorder.

From a psychosocial perspective, people with BDD may have experienced being teased about their appearance or made to feel sensitive in some other way during a time when their identities were in a critical period of formation. Once they start to believe that their bodily appearance is defective or deviates from the ideal to which they aspire, they become preoccupied with this belief, setting off a series of dysfunctional thoughts and repetitive behaviors. For example, they may look at an ordinary feature of their appearance, such as their waist size, and see only their “too large” waist when they view themselves. Their selective attention to this body part is accompanied by the belief

that no one could possibly like them, which in turn can lead them to avoid social situations and engage in rituals such as looking in the mirror and frequently studying their waist.

Clinicians treating clients with BDD from a cognitive-behavioral perspective focus on helping them to understand that appearance is only one aspect of their total identity, while at the same time challenging them to question their assumptions that their appearance is, in fact, defective. The clinician may also help these individuals realize that other people looking at them may not even be thinking about their appearance at all, or if so, not critically.

In one hands-on cognitive technique, clinicians encourage clients to look at themselves in a mirror and change their negative thoughts about what they see. Interpersonal therapy can also help people with BDD develop improved strategies for dealing with the distress they feel in their relationships with others, as well as addressing their low self-esteem and depressed mood.

Hoarding Disorder

In the compulsion known as hoarding, people have persistent difficulties discarding or parting with their possessions, even if they are not of much value. These difficulties include any form of discarding, including putting items into the garbage. People with hoarding disorder believe these items have utility or aesthetic or sentimental value, but in reality they often consist of old newspapers, bags, or leftover food.

When faced with the prospect of discarding the items, these individuals become

distressed, while their homes can become unlivable due to the clutter that

accumulates over the years. The rooms fill up with a mixture of objects that actually

are of value and items that ordinarily would be thrown away, such as old magazines.

Unlike ordinary collectors, who organize their items in a systematic way, people with

hoarding disorder accumulate items without any form of organization.

A substantial percentage of adults with hoarding disorder also have comorbid

depressive symptoms. Older adults who develop hoarding disorder are likely to

become physically and cognitively impaired, experiencing significant effects on their

daily functioning.

Hoarding Disorder

Treatment of Hoarding Disorder

Treatment of hoarding disorder that follows a biopsychosocial approach appears to be the most effective. Biological treatments have traditionally included SSRIs, but researchers believe the disorder may also have a neurocognitive component that would warrant treatment through addressing cognitive function. For example, people with hoarding disorder may have a form of ADHD in which they lack the ability to focus their attention on specific details. Hoarding disorder is also becoming understood from a developmental perspective as reflecting attachment difficulties and growing up in a household that lacked warmth.

Home visits in which the therapist uses cognitive-behavioral methods seem to hold the most promise, particularly in encouraging clients to discard their hoarded items. Practical assistance from movers or professional organizers may also be useful in supplementing medications and cognitive-behavioral treatment. Friends, family members, and local officials may also be consulted to assist in clearing the individual’s living space.

Trichotillomania (Hair-Pulling Disorder)

A diagnosis of trichotillomania (hair-pulling disorder) is given to individuals who pull out their hair in response to an increasing sense of tension or urge. After they pull their hair, they feel

temporary relief, pleasure, or gratification. People with trichotillomania are upset by their

uncontrollable behavior and may find that their social, occupational, or other areas of functioning are impaired because of the disorder. They feel unable to stop the behavior, even when it results in bald patches and lost eyebrows, eyelashes, armpit hair, and pubic hair. As they get older, they

increase the number of bodily sites from which they pull hair.

People with this disorder experience significant impairment in areas of life ranging from sexual intimacy to social activities, medical examinations, and haircuts. They can also develop skin

infections, scalp pain or bleeding, and carpal tunnel syndrome. Psychologically, they may suffer low self-esteem, shame and embarrassment, depressed mood, irritability, and argumentativeness. Their impairments appear early in life and continue through to middle and late adulthood. Those who also eat the hair they pull can develop hairballs, which settle in their gastrointestinal tract and cause abdominal pain, nausea and vomiting, weakness, and weight loss.

Trichotillomania

Diagnosable trichotillomania is relatively rare, with an estimated current prevalence rate of 0.6 percent. However, trichotillomania may be underreported because people with this disorder are secretive about the behavior and tend to engage in hair pulling only when alone.

In DSM-IV-TR trichotillomania was included in the category of impulse-control disorders, but in DSM-5 it moved to the category that includes obsessive-compulsive and related disorders. In addition, the name changed to hair pulling, which the DSM-5 authors concur is a better description of the disorder than “mania.”

There may be two types of hair pulling:

● In the “focused” type, which may account for one-quarter of cases, the individual is aware of having the urge to pull and may develop compulsive behaviors or rituals to avoid doing so. For people in the focused category, depression and disability are likely to occur along with stress and anxiety.

● In “automatic” hair pulling, the individual is engaged in another task or is absorbed in thought while pulling hair. Individuals who fall into the automatic category experience pronounced stress and anxiety.

Theories Behind Trichotillomania

Genetics seems to play an important role in trichotillomania, with an estimate of 80 percent heritability of the disorder. Abnormalities in a gene on chromosome 1 known as SLTRK1 may play a role in the disorder; this gene is also linked to Tourette’s disorder. Researchers have also identified abnormalities in SAPAP3, a gene related to glutamate, which in turn is implicated in obsessive-compulsive disorder. The neurotransmitters serotonin, dopamine, and glutamate are, in turn, thought to play a role in the development of trichotillomania. Brain imaging studies of individuals with trichotillomania suggest that they may also have abnormalities in brain regions active in attentional control, memory, and the ability to suppress automatic motor reactions.

Taking account of these abnormalities in neurotransmitter and brain functioning, the regulation model of trichotillomania suggests that individuals with this disorder seek an optimal state of emotional arousal, providing them with greater stimulation when they are understimulated and calming them when they are overstimulated. At the same time, hair pulling may bring them from a negative to a positive affective state.

Using the Trichotillomania Symptoms Questionnaire, researchers conducting an online survey found that individuals who engaged in hair pulling experienced more difficulty controlling their emotions than those who did not. There were subgroups in the sample, which varied in whether the subjects were more likely to experience boredom or anxiety and tension, and in the overall intensity of emotions they felt that seemed to drive them toward hair pulling. The researchers suggested that these subgroups on the questionnaire seemed to correspond to the automatic and focused subtypes of the disorder.

Trichotillomania Symptoms

Questionnaire

1. Do you currently pull your hair out?

2. At any point in your life, including now, have you had periods of uncontrollable hair-pulling?

3. Do you (or did you in the past) experience urges to pull your hair out?

4. Do you (or did you in the past) try to resist pulling your hair out?

5. Do you (or did you in the past) feel relief when pulling your hair out?

6. Do you (or did you in the past) wish that the urge to pull your hair out would go away?

7. Have you been diagnosed with trichotillomania by a professional?

8. Do you, or did you in the past, feel shame, secrecy, or distress about your hair-pulling?

Trichotillomania Treatment

Pharmacological treatments for trichotillomania include antidepressants, atypical antipsychotics, lithium, and naltrexone. Of these, naltrexone seems to have shown the most promising results. However, the results of controlled studies are not compelling and do not seem to justify the use of medications when weighed against the side effects, which can include obesity, diabetes, neurotoxicity, delirium, encephalopathy, tremors, and hyperthyroidism, among others.

The behavioral treatment of habit reversal training (HRT) is regarded as the most effective approach to treating trichotillomania. Not only does this method prevent the side effects of medication, but it is more successful in reducing the symptoms of hair pulling; however, for treatment-resistant individuals, a combination of medication and HRT may be required. In HRT, the individual learns a new response to compete with the habit of hair pulling, such as fist clenching. The key feature is that the new response is incompatible with the undesirable habit. Dialectical behavior therapy (DBT) may add to these methods a combination of mindfulness training, in which clients learn to identify the cues that trigger their hair pulling, and imagery training, in which they visualize themselves in a tranquil state.

Combining acceptance and commitment therapy (ACT) with HRT is also shown to produce relief from hair-pulling symptoms. Cognitive-behavioral therapy can help in treating children and adolescents with trichotillomania, with very little alteration from the basic protocol used for adults. In one study, 77 percent of those who received treatment remained symptom-free after 6 months. An advantage of ACT for this disorder is that it can be administered along with cognitive-behavioral treatment in a group format with results as effective as those obtained with individual therapy.

Although trichotillomania can be a highly disabling condition, there is promise in the range of therapies based on behavior therapy, cognitive-behavior therapy, and the newer approaches that help individuals identify and cope with the feelings associated with the behavior. Newer therapies are also including psychoeducation to provide clients with the opportunity to gain insight into their disorder.

Excoriation (Skin-Picking) Disorder

In a new diagnosis in DSM-5, individuals are regarded as having excoriation (skin-picking) disorder if they repeatedly pick at their own skin, perhaps as much as several hours a day. The skin picking may be of healthy skin, skin with mild irregularities (such as moles), pimples, calluses, or scabs. People with this disorder pick at these bodily areas either with their own fingernails or with instruments such as tweezers. When they are not picking their skin, they think about picking it and try to resist their urges to do so. They may attempt to cover the evidence of their skin picking with clothing or bandages, and they feel ashamed of and embarrassed about their behavior.

Because this is a new diagnosis, epidemiological data are limited,

but DSM-5 estimates the prevalence as at least 1.4 percent of

adults, three-quarters of whom are female. Researchers believe skin

picking is valid as a distinct diagnosis from trichotillomania.

However, the two disorders share causes and effective treatment

approaches. For some individuals with excoriation disorder, high

levels of impulsivity also appear to play an important role.

Trauma and Stressor-Related Disorders

Individuals who are exposed to trauma or a stressful event may be at risk for developing a psychological disorder. The category of trauma- and stressor-related disorders have as a diagnostic criterion the condition of an actual event that acts as a precipitant.

DSM-5 includes disorders in this group that were originally in their own category within the anxiety disorders. The DSM-5 also places into this category a set of disorders in childhood that can be traced to exposure to stress or trauma.

Reactive Attachment and Disinhibited Social Engagement Disorder

In this first of the trauma- and stressor-related disorders we find reactive attachment disorder (RAD), a diagnosis given to children who literally “react against” attachment to others.

Their symptoms include becoming withdrawn and inhibited. They tend not to show positive affect, but they also lack the ability to control their emotions. Unlike normal children, when they become distressed, they do not seek comfort from adults.

The diagnosis of disinhibited social engagement disorder describes an opposite situation in which a child with a history of trauma engages in culturally inappropriate, overly familiar behavior with people who are relative strangers.

These disorders are placed among the trauma- and stressor-related disorders because they are found in children who have experienced an abuse pattern of social neglect, repeated changes of primary caregivers, or rearing in institutions with high child-to-caregiver ratios. Consequently, such children are significantly impaired in their ability to interact with other children and adults.

Acute Stress Disorder

A trauma is said to occur when an individual is exposed, either once or repeatedly, to circumstances that are harmful or life threatening and that have lasting adverse effects on the individual’s functioning and mental health. When people are exposed to the threat of death, or to actual or threatened serious injury, or sexual violation, they risk developing acute stress disorder. Being exposed to the death of others, or to any of these events, real or threatened, to others can also lead to the development of this disorder.

The symptoms of acute stress disorder fall into four categories: intrusion of distressing reminders of the event, dissociative symptoms such as feeling numb or detached from others, avoidance of situations that might serve as reminders of the event, and hyperarousal including sleep disturbances or irritability. The symptoms may persist for a few days to a month after the traumatic event.

Post Traumatic Stress Disorder

The events that can cause acute stress disorder may lead to the longer-lasting disorder known as post-traumatic stress disorder (PTSD).

If the individual experiences acute stress disorder symptoms for more than a month, the clinician assigns the PTSD diagnosis.

The intrusions, dissociation, and avoidance seen in acute stress disorder are also present in PTSD.

Symptoms also include loss of memory of the event, excessive self-blame, distancing from others, and inability to experience positive emotions.

Post Traumatic Stress Disorder

The diagnosis of PTSD has a long history. The Vietnam War was perhaps the most publicized war to produce psychological casualties, but reports of psychological dysfunction following exposure to combat emerged after the Civil War. In World Wars I and II, the condition was referred to with such terms as shell shock, traumatic neurosis, combat stress, and combat fatigue. Survivors of European concentration camps in the 1930s and 1940s also were reported to suffer long-term psychological effects, including chronic depression, anxiety, and difficulties in interpersonal relationships due to guilt over having survived when so many others were killed.

Although PTSD is often studied among male combat veterans, researchers are beginning to examine the phenomenon in women exposed to trauma during their military service. A traumatic experience more likely to affect women than men is sexual assault. Women exposed to combat-related trauma and sexual assault show a cumulatively higher risk of developing both PTSD and substance use disorders

Theories and Treatment of PTSD

A traumatic experience is an external event that impinges on the individual and hence does not have biological “causality.” However, researchers propose that traumatic experiences have their impact in part because they do lead to changes in the brain that make certain regions primed or hypersensitive to possible danger in the future. Individuals with PTSD experience alterations in the hippocampus, the structure in the brain responsible for consolidating short-term memory. As a result, these individuals become unable to distinguish relatively harmless situations (such as fireworks) from the ones in which real trauma occurred (such as combat). They continue to re-experience the event with heightened arousal and therefore avoid situations that resemble those in which they were traumatized.

SSRI antidepressants are the only FDA-approved medications for people with PTSD. However, the response rates of patients with PTSD to these medications are rarely more than 60 percent, and fewer than 20 to 30 percent achieve full remission of their symptoms. Research does not support the use of benzodiazepines in treatment of PTSD, although these medications may relieve insomnia or anxiety. Although researchers believed the antipsychotic medication risperidone might benefit individuals with PTSD, findings from a large-scale study of nearly 300 veterans did not provide empirical support for its use in reducing symptoms.

From a psychological perspective, people with PTSD have a biased information-processing style that, due to the trauma they experienced, causes their attention to be highly attuned toward potentially threatening cues. Therefore they are more likely to feel that they are in danger, and also are more likely to avoid situations they perceive as potentially threatening. Personality and coping style also predict responses to trauma, including high levels of neuroticism and extreme sensitivity to internal cues of anxiety.

Theories and Treatment of PTSD

Generally considered the most effective psychological treatment for PTSD, cognitive-behavioral therapy combines some type of exposure (in vivo or imaginal) with relaxation and cognitive restructuring. Specific trauma-focused psychotherapy that focuses on memory of the traumatic event or its meaning is gaining support as a first-line treatment. Trauma-focused therapy produces longer-lasting results without the side effects associated with psychotropic interventions. The American Psychological Association’s Clinical Practice Guidelines for the Treatment of PTSD in Adults also strongly recommended cognitive-behavioral and exposure therapy and, if medication is indicated, the use of SSRIs but not antipsychotics.

Because trauma is so often a component of other disorders, including substance use disorders, the U.S. government’s Substance Abuse and Mental Health Services Administration (SAMHSA) has compiled a treatment manual for clinicians working in behavioral health. This manual is based on the principles of trauma informed care, a model that promotes trauma awareness and understanding to professionals treating individuals with a history of trauma. The idea of resilience is central to this philosophy of treatment, helping individuals foster their own inner strengths as they develop a greater sense of competence. Furthermore, according to the principles of trauma informed care, clinicians must avoid retraumatizing clients who already have histories of trauma.

Couples therapy is another method that can prove beneficial in reducing symptoms as well as reducing distress both in the individual and in the individual’s partner. Such an approach can help lower reintegration stress in both partners, improving their communication and expression of intimacy and reducing the number of disagreements about parenting.

Post-Traumatic

Growth An alternative view to PTSD comes from the

field of positive psychology, which proposes

that people can grow through the experience

of trauma, a phenomenon known as

post-traumatic growth.

According to this approach, trauma can allow

clients to cope by developing positive

interpretations of their experiences.

Anxiety,

Obsessive-Compulsive, and Trauma- and

Stressor-Related Disorders: The Biopsychosocial

Perspective

The disorders we covered in this lecture span a broad spectrum of problems, ranging from specific and seemingly idiosyncratic responses to diffuse and undifferentiated feelings of dread. There are differences among the disorders in symptoms and causes, but there do seem to be important similarities in that they all involve regions of the brain active in responding to fearful or threatening situations. Perhaps what determines whether an individual with a propensity toward developing an anxiety disorder does so are the combined effects of genetics, brain functioning, life experiences, and social context. Across these disorders, there also appear to be similarities in treatment approach, with cognitive-behavioral methods showing perhaps the greatest effectiveness.

Sources

Image 1: https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder.shtml

Image 2: https://www.therecoveryvillage.com/mental-health/separation-anxiety/

Image 3: https://www.wsj.com/articles/virtual-reality-as-a-therapy-tool-1443260202

Image 4: https://www.verywellmind.com/social-anxiety-disorder-symptoms-and-diagnosis-4157219

Image 5: https://www.verywellmind.com/social-anxiety-disorder-causes-3024749

Image 6: https://www.verywellmind.com/top-symptoms-of-panic-attacks-2584270

Image 7: https://www.findatopdoc.com/Top-Videos-and-Slideshows/Agoraphobia

Image 8: https://www.verywellmind.com/dsm-5-criteria-for-generalized-anxiety-disorder-1393147

Image 9: https://www.verywellmind.com/gad-causes-risk-factors-1392982

Image 10: https://www.helpguide.org/articles/anxiety/obssessive-compulsive-disorder-ocd.htm

Image 11: https://www.wikihow.com/Cope-With-Obsessive-Compulsive-Disorder

Image 12: https://metro.co.uk/2018/03/02/three-people-reveal-what-its-like-to-live-with-body-dysmorphic-disorder-7355573/ Image 13: https://coard.psychiatry.ufl.edu/hoarding-2/

Image 14: https://www.trichstop.com/info

Image 15: http://coard.psychiatry.ufl.edu/research/participate-in-research/

Images 16-18: https://mindcology.com/mental-health/anxiety/statistics-acute-stress-disorder-infographic/

Image 19: https://synapse.koreamed.org/ViewImage.php?Type=F&aid=17747&id=F1&afn=55_JKNA_54_1_32&fn=jkna-54-32-g001_0055JKNA

Video 1: https://www.youtube.com/watch?v=PCOg2G797ek

Video 2: https://www.youtube.com/watch?v=PnV6KqJ0OfU

Text: Whitbourne, Susan Krauss. Abnormal Psychology: Clinical Perspectives on Psychological Disorders. McGraw-Hill Higher Education. Kindle Edition.