DB 4 - Chapter Three: Topic - Schizophrenia

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Anxiety, Obsessive-Compulsive, and Related Disorders

Chapter 4

Fundamentals of Abnormal Psychology

RONALD J. COMER | JONATHAN S. COMER| ninth edition

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Anxiety Disorders (part 1)

Fear

Central nervous system’s physiological and emotional response to a serious threat to one’s well-being

Anxiety

Central nervous system’s physiological and emotional response to a vague sense of threat or danger

Generalized anxiety disorder

Disorder marked by persistent and excessive feelings of anxiety and worry about numerous events and activities

Anxiety Disorders (part 2)

Most common mental disorders in the United States

In any given year, 18 percent of the U.S. adult population experiences one of the six DSM-5 anxiety disorders

About 29 percent develop one of the disorders at some point in their lives

About one-third of these individuals seek treatment

Most individuals with one anxiety disorder also suffer from a second disorder.

In addition, many individuals with an anxiety disorder experience depression.

Generalized Anxiety Disorder (part 1)

GAD checklist

For 6 months or more, the person experiences disproportionate, uncontrollable, and ongoing anxiety and worry about multiple matters

The symptoms include at least three of the following: edginess, fatigue, poor concentration, irritability, muscle tension, sleep problems

Significant distress or impairment

Information from APA, 2013.

Generalized Anxiety Disorder (part 2)

Sociocultural perspective

GAD is most likely to develop in people faced with dangerous ongoing social conditions

Supported by research findings

Forms of societal stress

Poverty

Race and ethnicity

Since race is closely tied to stress in the United States, it is not surprising that it is also tied to the prevalence of GAD.

In any given year, African Americans are 30 percent more likely than white Americans to suffer from GAD.

Multicultural researchers have not consistently found a heightened rate of GAD among Hispanics in the United States, although they do note the prevalence of nervios in that population.

Although poverty and other social pressures may create a climate for GAD, other factors are clearly at work.

Most people living in “dangerous” environments do not develop GAD.

Other models attempt to explain why some people develop the disorder and others do not.

Generalized Anxiety Disorder (part 3)

Prevalence of Anxiety Disorders and Obsessive-Compulsive Disorder (Compared with Rate in Total Population)
	Female	Low-Income	Elderly
Generalized anxiety disorder	Higher	Higher	Higher
Specific phobias	Higher	Higher	Lower
Agoraphobia	Higher	Higher	Higher
Social anxiety disorder	Higher	Higher	Lower
Panic disorder	Higher	Higher	Lower
Obsessive-compulsive disorder	Same	Higher	Lower

Separation Anxiety: Not Just for Kids

Most common disorder among young children

DSM-5 determined separation anxiety can develop in adults

New categorization as an anxiety disorder is controversial

Only for children?

Generalized Anxiety Disorder (part 4)

Psychodynamic perspective

Freud posited that all children experience anxiety

Realistic anxiety when they face actual danger

Neurotic anxiety when they are prevented from expressing id impulses

Moral anxiety when they are punished for expressing id impulses

Some children experience particularly high levels of anxiety or their defense mechanisms are particularly inadequate

Today's psychodynamic theorists often disagree with specific aspects of Freud's explanation.

Researchers have found some support for the psychodynamic perspective:

People with GAD are particularly likely to use defense mechanisms (especially repression).

Adults, who as children suffered extreme punishment for expressing id impulses, have higher levels of anxiety later in life.

Some scientists question whether these studies show what they claim to show.

Generalized Anxiety Disorder (part 5)

Psychodynamic perspective

Psychodynamic therapies

Free association

Therapist interpretations of transference, resistance, and dreams

Specific treatments for GAD

Freudians focus less on fear and more on control of id

Object-relations therapists attempt to help patients identify and settle early relationship problems

Short-term psychodynamic therapy is more effective

Controlled studies have typically found psychodynamic treatments to be of only modest help to persons with GAD.

Short-term psychodynamic therapy may be the exception to this trend.

Generalized Anxiety Disorder (part 6)

Humanistic perspective

GAD arises when people stop looking at themselves honestly and acceptingly

Carl Rogers' explanation

Lack of unconditional positive regard in childhood leads to conditions of worth (i.e., harsh self-standards)

Threatening self-judgments break through and cause anxiety, setting the stage for GAD to develop

Generalized Anxiety Disorder (part 7)

Humanistic perspective

Client-centered approach used to show unconditional positive regard for clients and to empathize with them

Despite optimistic case reports, controlled studies have failed to offer strong support

Only limited support for Rogers' explanation of GAD and other forms of abnormal behavior

Generalized Anxiety Disorder (part 8)

Cognitive-behavioral perspective

Problematic behaviors and dysfunctional thinking often cause psychological disorders

Treatment focus involves the nature of behavior and thoughts

Early approach

Maladaptive or basic irrational assumptions (Ellis)

Silent assumptions (Beck)

Initially, theorists suggested that GAD is caused by maladaptive assumptions.

Albert Ellis identified basic irrational assumptions:

It is a dire necessity for an adult human being to be loved or approved of by virtually every significant person in his community.

It is awful and catastrophic when things are not the way one would very much like them to be.

When these assumptions are applied to everyday life and to more and more events, GAD may develop.

Aaron Beck, another cognitive theorist, argued that persons with GAD constantly hold silent assumptions that imply imminent danger:

A situation/person is unsafe until proved safe.

It is always best to assume the worst.

Researchers have repeatedly found that people with GAD do hold maladaptive assumptions, particularly about dangerousness.

Generalized Anxiety Disorder (part 9)

Cognitive-behavioral perspective

Newer explanations

Metacognitive theory (Wells) and meta-worries

Intolerance of uncertainty theory (Koerner and colleagues)

Avoidance theory (Borkovec)

How Long Do Your Worries Last?

In one survey, 62 percent of college students said they spend less than 10 minutes at a time worrying about something. In contrast, 20 percent worry for more than an hour. (Information from Tallis, 2015, 2014; Tallis et al., 1994.)

In recent years, several new explanations have emerged:

Metacognitive theory: Developed by Wells; suggests that the most problematic assumptions in GAD are the individual's worry about worrying (meta-worry)

Uncertainty theory: Certain individuals consider it unacceptable that negative events may occur, even if the possibility is very small; they worry in an effort to find “correct” solutions

Avoidance theory: Developed by Borkovec; holds that worrying serves a “positive” function for those with GAD by reducing unusually high levels of bodily arousal

Generalized Anxiety Disorder (part 10)

Cognitive-behavioral therapies

Changing maladaptive assumptions

Ellis's rational-emotive therapy (RET)

Breaking down worrying

Mindfulness-based cognitive-behavioral therapy

Acceptance and commitment therapy

Generalized Anxiety Disorder (part 11)

Biological perspective

GAD is caused chiefly by biological factors

Supported by family pedigree studies and brain researchers

Challenged by competing explanation of shared environment

Fear reactions are tied to brain circuits

Biological relatives more likely to have GAD (approximately 15 percent): The closer the relative, the greater the likelihood.

There is, however, a competing explanation of shared environment.

Generalized Anxiety Disorder (part 12)

Biological perspective

GAD results from a hyperactive fear circuit

GABA: Important neurotransmitter in this circuit

Involves several brain structures

Prefrontal cortex

Anterior cingulate cortex

Insula

Amygdala

Bed nucleus of stria terminals (BNST) may play large or larger role than other structures

The Biology of Anxiety

The circuit in the brain that helps produce anxiety reactions includes structures such as the amygdala, prefrontal cortex, anterior cingulate cortex, and insula (not visible from this view of the brain).

In normal fear reactions:

Key neurons fire more rapidly, creating a general state of excitability experienced as fear or anxiety.

A feedback system is triggered, so that brain and body activities work to reduce excitability.

Some neurons release GABA to inhibit neuron firing, thereby reducing experience of fear or anxiety.

Malfunctions in the feedback system are believed to cause GAD.

Possible reasons: Too few receptors, ineffective receptors

Recent research has complicated the picture:

Other neurotransmitters also bind to GABA receptors.

Issue of causal relationships:

Do physiological events CAUSE anxiety?

How can we know?

What are alternative explanations?

Generalized Anxiety Disorder (part 13)

Biological perspective

Drug therapy

Early 1950s: Barbiturates (sedative-hypnotics)

Late 1950s: Benzodiazepines

More recently: Antidepressant and antipsychotic medications

Generic Name	Trade Name
Alprazolam	Xanax
Chlordiazepoxide	Librium
Clonazepam	Klonopin
Clorazepate	Tranxene
Diazepam	Valium
Estazolam	ProSom
Lorazepam	Ativan
Midazolam	Versed
Oxazepam	Serax

Benzodiazepines:

Provide temporary, modest relief

Rebound anxiety with withdrawal and cessation of use

Physical dependence is possible

Produce undesirable effects (e.g., drowsiness)

Mix badly with certain other drugs (especially alcohol)

Phobias (part 1)

Fear

A normal and common experience

How do phobias differ from fear?

More intense and persistent fear

Greater desire to avoid the feared object or situation

Create distress that interferes with functioning

Biggest Existential Fears
Failure	Pain	Loneliness
Death	The unknown	Uncertainty
Rejection	Loss of freedom	Separation
Ridicule	Inadequacy	Being unimportant
Misery	Being judged	Deprivation
Disappointment	Change

Phobias (part 2)

Categories of phobias

Specific phobias

Agoraphobia

Persistent and unreasonable fears of particular objects, activities, or situations

Avoidance of the object or thoughts about it

Phobias (part 3)

Specific Phobias

Yearly symptoms exist in 10 percent of all U.S. people

14 percent of people experience symptoms during lifetime

Women outnumber men 2:1

32 percent seek treatment

Checklist

Marked, persistent, and disproportionate fear of a particular object or situation; usually lasting at least 6 months

Exposure to the object produces immediate fear

Avoidance of the feared situation

Significant distress or impairment

Most common phobias: Specific animals or insects, heights, enclosed spaces, thunderstorms, and blood

Information from APA, 2013.

Phobias (part 4)

Agoraphobia

Yearly symptoms exist in 1.7 percent of U.S. population

2.6 percent of people experience symptoms during lifetime; gender differences

46 percent seek treatment

Checklist

Pronounced, disproportionate, or repeated fear about being in at least two delineated situations

Avoidance of the agoraphobic situations

Symptoms usually continue for at least 6 months

Significant distress or impairment; often fluctuates

Pronounced, disproportionate, or repeated fear about being in at least two of the following situations:

Public transportation (e.g., auto or plane travel)

Parking lots, bridges, or other open spaces

Shops, theaters, or other confined places

Lines or crowds

Away from home unaccompanied

Fear of such agoraphobic situations derives from a concern that it would be hard to escape or get help if panic, embarrassment, or disabling symptoms were to occur.

Information from APA, 2013.

Phobias (part 5)

What causes specific phobias?

Evidence supports the behavioral explanations

Cognitive-behavioral theory

Behavioral-evolutionary explanation

Phobias, not Although these young women cling tightly to each other, frozen with fear as they try to walk across a bridge, they are not displaying abnormal fear or a phobia. A closer look reveals that the bridge, which stands 600 feet high and spans 1000 feet, has a glass floor, the first of its kind in China. Almost all visitors to this new tourist destination initially experience the same emotional reaction— overwhelming and near-paralyzing fear.

Phobia (part 6)

Cognitive-behavioral perspective

How are fears learned?

Classical conditioning

US: Entrapment  UR: Fear

CS: Running water  CR: Fear

Modeling

Observation

Imitation

Phobias develop through modeling:

Observation and imitation

Phobias are maintained through avoidance.

Phobias may develop into GAD when a person acquires a large number of them.

Process of stimulus generalization: Responses to one stimulus are also elicited by similar stimuli.

Phobia (part 7)

Cognitive-behavioral perspective

What does research indicate?

Early laboratory studies of classical conditioning of fear: Watson and Rayner (Little Albert)

Modeling: Bandura and Rosenthal

Fear reactions not always conditioned

McGabe and Gamble and colleagues

Disorder not ordinarily acquired through classical conditioning or modeling

Phobias (part 8)

Behavioral-evolutionary perspective

Some specific phobias are much more common than others

Species-specific biological predisposition to develop certain fears: preparedness

Explains why some phobias (snakes, spiders) are more common than others (meat, houses)

Is a mouse’s fear of cats a conditioned reaction or genetically hardwired? Scientists at Tokyo University used genetic engineering to switch off this rodent’s instinct to cower at the smell or presence of cats. But mouse beware! The cat has not been genetically engineered to act in a corresponding manner.

Researchers do not know if these predispositions are due to evolutionary or environmental factors.

Phobias (part 9)

Behavioral-evolutionary perspective

Treatments for specific phobias

Actual contact with the feared object or situation is key to greater success in all forms of exposure treatment

Systematic desensitization (Wolpe)

Covert and in vivo desensitization, including virtual reality

Flooding

Modeling

Since relaxation is incompatible with fear, the relaxation response is thought to substitute for the fear response.

Teach relaxation skills → Create fear hierarchy → Pair relaxation with the feared objects or situations

Types:

In vivo desensitization (live)

Covert desensitization (imaginal)

Phobias (part 10)

Treatments for agoraphobia

Older approaches are less successful

Newer, more successful treatments

Variety of exposure therapy approaches

Support groups

Home-based self-help programs

Are successful for about 70 percent of agoraphobic clients

Relapses may occur, especially when panic disorder also exists

Often explained in ways similar to specific phobias

Many people with agoraphobia experience extreme and sudden explosions of fear, called panic attacks,

Such individuals may receive two diagnoses—agoraphobia and panic disorder.

Social Anxiety Disorder (part 1)

Social Anxiety Disorder

Yearly symptoms exist in 8 percent of U.S. population

13 percent of people experience symptoms during lifetime

Non-Hispanic white Americans more likely to experience than African, Hispanic, or Asian Americans

Often begins in late childhood or adolescence and into adulthood

40 percent seek treatment

Checklist

Pronounced, disproportionate, and repeated anxiety about social situation(s) in which the individual could be exposed to scrutiny by others; typically lasting 6 months or more

Fear of being negatively evaluated by or offensive to others

Exposure to the social situation almost always produces anxiety

Avoidance of feared situations

Significant distress or impairment

Marked, disproportionate, and persistent fears about one or more social situations.

May be narrow: Talking, performing, eating, or writing in public

May be broad: General fear of functioning poorly in front of others

In both forms, people rate themselves as performing less competently than they actually do.

Information from APA, 2013.

Social Anxiety Disorder (part 2)

Cognitive-behavioral perspective

Leading explanation for this disorder features cognitive and behavioral factors

Group of social-realm dysfunctional beliefs and expectations held

Anticipation of social disasters and dread of social situations

Avoidance and safety behaviors performed to reduce or prevent these disasters

Cognitive theorists hold that, because of these beliefs, people with social anxiety disorder keep anticipating that social disasters will occur, and they repeatedly perform “avoidance” and “safety” behaviors to help prevent or reduce such disasters.

Social Anxiety Disorder (part 3)

Treatments for social anxiety disorder

Overwhelming social fears: Addressed behaviorally with exposure

Cognitive-behavioral therapy: Exposure therapy and systematic therapy discussions

Medications: Benzodiazepine or antidepressant drugs

Lack of social skills

Social skills and assertiveness training

Unlike specific phobias, social anxiety disorders are often reduced through medication (particularly antidepressants).

Several types of psychotherapy have proved at least as effective as medication.

People treated with psychotherapy are less likely to relapse than people treated with drugs alone.

One psychological approach is exposure therapy, either in an individual or a group setting.

Cognitive therapies have also been widely used.

Another treatment option is social skills training, a combination of several behavioral techniques to help people improve their social functioning.

Therapists provide feedback and reinforcement.

Social skills training groups and assertiveness training groups allow clients to practice their skills with other group members.

MindTech: Social Media Jitters

Computer and mobile device use can produce more common forms of anxiety, including social and generalized anxiety

Facebook, Instagram, or Snapchat

Can you think of ways or reasons why negative feelings might be triggered by social networking? How about positive feelings?

Panic Disorder (part 1)

Panic attacks

Periodic, short bouts of panic that occur suddenly, reach a peak within minutes, and gradually pass

Feature at least four of the following symptoms of panic:

Heart palpitations

Tingling in the hands or feet

Shortness of breath

Sweating

Hot and cold flashes

Trembling

Chest pains

Choking sensations

Faintness

Dizziness

Feeling of unreality (APA, 2013)

Women are twice as likely as men to be affected.

Poor people are 50 percent more likely than wealthier people to experience these disorders.

The prevalence is the same across cultural and racial groups in the United States and seems to occur in cultures across the world.

Approximately 35 percent of persons with panic disorder are in treatment.

Panic Disorder (part 2)

Panic Disorder

3.1 percent of U.S. population experience this disorder yearly

More than 5 percent of people experience symptoms during lifetime

Often begins in late adolescence or early adulthood

Non-Hispanic white Americans more likely to experience than U.S. racial-ethnic minority groups

59 percent seek treatment

May be accompanied by agoraphobia

Checklist

Unforeseen panic attacks occur repeatedly

One or more of the attacks precede either of the following symptoms:

At least a month of continual concern about having additional attacks

At least a month of dysfunctional behavior changes associated with the attacks (e.g., avoiding new experiences)

Panic Disorder (part 3)

Biological perspective

Initial theory

Panic attacks caused by abnormal norepinephrine activity in locus coeruleus

More recent theory

Brain circuits and amygdala are the more complex root of the problem

May be an inherited predisposition to abnormalities in these areas

Panic Disorder (part 4)

Biological perspective

Caused by a hyperactive panic circuit

Amygdala

Hippocampus

Ventromedial nucleus of hypothalamus

Central gray matter

Locus coeruleus

The Biology of Panic The circuit in the brain that helps produce panic reactions includes structures such as the amygdala, hippocampus, ventromedial nucleus of the hypothalamus, central gray matter, and locus coeruleus.

Panic Disorder (part 5)

Drug therapies

Various antidepressants bring some improvement to more than two-thirds of patients

Function in norepinephrine receptors in the panic brain circuit

Improvements require maintenance of drug therapy

Some benzodiazepines (especially Xanax [alprazolam]) have proved helpful

Panic Disorder (part 6)

Cognitive-behavioral perspective

Biological factors are only part of the cause of panic attacks

Bodily sensations are misinterpreted as signs of medical catastrophe and controlled by avoidance and safety behaviors

Anxiety sensitivity may exist

Biological challenge test

Procedure used to produce panic and assess panic disorder

Misinterpreting bodily sensations

Panic-prone people may be very sensitive to certain bodily sensations and may misinterpret them as signs of a medical catastrophe; this leads to panic.

Why might some people be prone to such misinterpretations?

Experience more frequent or intense bodily sensations

Have experienced more trauma-filled events

Whatever the precise cause, panic-prone people generally have a high degree of “anxiety sensitivity.”

They focus on bodily sensations much of the time, are unable to assess the sensations logically, and interpret them as potentially harmful.

Panic Disorder (part 7)

Cognitive therapy

Seeks to correct people's misinterpretations of their bodily sensations

Educate about the nature of panic attacks

Teach applications of more accurate interpretations

Teach skills for coping with anxiety, including biological challenge procedures

Cognitive treatments often help people with panic disorder.

Approximately 80 percent of treated patients are panic-free for two years compared with 13 percent of control subjects.

Such treatments also are helpful for treating panic with agoraphobia; in those cases, therapists often add exposure techniques to the cognitive aspects of treatment.

At least as helpful as antidepressants

Combination therapy may be most effective.

Still under investigation

Obsessive-Compulsive Disorder (part 1)

Obsessions

Persistent thoughts, ideas, impulses, or images that seem to invade a person's consciousness

Compulsions

Repetitive and rigid behaviors or mental acts that people feel they must perform to prevent or reduce anxiety

Normal Routines Most people find it comforting to follow set routines when they carry out everyday activities, and, in fact, 40 percent become irritated if they must depart from their routines. (Information from: Kanner, 2005, 1998, 1995.)

Obsessive-Compulsive Disorder (part 2)

OCD

Related to other disorders in features, causes, and treatment responsiveness

Affects 1 to 2 percent of world population

Begins in childhood or young adulthood; fluctuating severity

Equally common among men and women and racial and ethnic groups

40 percent seek treatment

Checklist

Occurrence of repeated obsessions, compulsions, or both

The obsessions or compulsions take up considerable time

Significant distress or impairment

Classified as an anxiety disorder because obsessions cause anxiety, while compulsions are aimed at preventing or reducing anxiety

Anxiety rises if obsessions or compulsions are resisted.

Between 1 percent and 2 percent of U.S. population suffer from OCD in a given year, and as many as 3 percent over a lifetime.

Equally common in men and women and among different racial and ethnic groups

Obsessive-Compulsive Disorder (part 3)

Obsessions

Features

Thoughts that feel both intrusive and foreign

Attempts to ignore or resist them trigger anxiety

Basic themes

Dirt/contamination

Violence and aggression

Orderliness

Religion

Sexuality

Obsessive-Compulsive Disorder (part 4)

Compulsions

Features

Various forms of voluntary behaviors or mental acts

Feel mandatory/unstoppable

Most people recognize that their behaviors are unreasonable

Performing behaviors reduces anxiety for a short time

Behaviors often develop into rituals

Themes

Cleaning

Checking

Order or balance

Touching, verbalizing, and/or counting

Most people with OCD experience both obsessions and compulsions.

Compulsive acts often occur in response to obsessive thoughts.

Compulsions seem to represent a yielding to obsessions.

Compulsions sometimes serve to help control obsessions.

Obsessive-Compulsive Disorder (part 5)

Psychodynamic perspective

Theory

Battle between the id and the ego defense mechanisms lessens anxiety in overt thoughts and actions

Freud: OCD related to the anal stage of development

Not all psychodynamic theorists agree

Treatment

Classical techniques of free association and therapist interpretation; have little research support

Short-term psychodynamic therapies are more direct and action-oriented

Three ego defense mechanisms are common:

Isolation: Disown disturbing thoughts

Undoing: Perform acts to “cancel out” thoughts

Reaction formation: Take on lifestyle in contrast to unacceptable impulses

Psychodynamic therapies

Goals are to uncover and overcome underlying conflicts and defenses.

Main techniques are free association and interpretation.

Research has offered little evidence to support the therapies.

Some therapists now prefer to treat these patients with short-term psychodynamic therapies.

Obsessive-Compulsive Disorder (part 6)

Cognitive-behavioral perspective

Disorder grows from human tendencies to have unwanted and unpleasant thoughts

To avoid negative outcomes, individuals attempt to neutralize their thoughts with actions (or other thoughts)

Seeking reassurance

Thinking “good” thoughts

Washing

Checking

Everyone has repetitive, unwanted, and intrusive thoughts.

People with OCD blame themselves for normal (although repetitive and intrusive) thoughts and expect that terrible things will happen as a result.

Obsessive-Compulsive Disorder (part 7)

Behavioral therapy

Focus on the cognitive processes that help to produce and maintain obsessive thoughts and compulsive acts

Use exposure and response prevention exercises (ERP) (Meyer)

Set example

Use videoconferencing in recent years

Between 50 and 70 percent improvement with therapy

People with OCD tend to:

Be more depressed than others

Have exceptionally high standards of conduct and morality

Believe thoughts are equal to actions and are capable of bringing harm

Believe that they can, and should, have perfect control over their thoughts and behaviors

Obsessive-Compulsive Disorder (part 8)

Biological perspective

Early research

Family pedigree and twin studies

Recent research

Abnormal serotonin activity

Abnormal brain structure and functioning

Some research evidence suggests these two lines may be connected

The brain circuit that has been linked to obsessive-compulsive disorder includes structures such as the orbitofrontal cortex, cingulate cortex, striatum, thalamus, and amygdala.

Abnormal serotonin activity:

Evidence that serotonin-based antidepressants reduce OCD symptoms

Recent studies have suggested other neurotransmitters also may play important roles

Abnormal brain structure and functioning:

OCD linked to orbitofrontal cortex and caudate nuclei

Frontal cortex and caudate nuclei make up the brain circuit that converts sensory information into thoughts and actions

Either area may be too active, letting through troublesome thoughts and actions

Some research provides evidence that these two lines may be connected.

Serotonin (with other neurotransmitters) plays a key role in the operation of the orbitofrontal cortex and the caudate nuclei.

Abnormal neurotransmitter activity could contribute to the improper functioning of the circuit.

Obsessive-Compulsive Disorder (part 9)

Biological treatment

Serotonin-based antidepressants

Clomipramine (Anafranil) and similar drugs

Improvement in 50 to 80 percent of those with OCD

Relapse occurs if medication is stopped

Research suggests that combination therapy (medication + cognitive-behavioral therapy approaches) may be most effective

Obsessive-Compulsive Disorder (part 10)

Obsessive-compulsive-related disorders

DSM-5 created obsessive-compulsive-related disorders

Hoarding disorder

Trichotillomania (hair-pulling disorder)

Excoriation (skin-picking) disorder

Body dysmorphic disorder

A messy aftermath This man prepares to clean out his mother’s home after her death. This is not an easy task—emotionally or physically—under the best of circumstances, but it is particularly difficult in this instance: his mother had suffered from hoarding disorder.

Integrating the Models

Developmental psychopathology perspective

Examination of how key factors emerge and intersect at points throughout the life span

General foci

Genetic factors

Hyperactive fear circuit in brain

Inhibited temperament

Parenting style

Maladaptive thinking

Avoidance behaviors

Life stress

Negative social factors