Chapter 5

Anxiety, Trauma-and Stressor-Related, and Obsessive-Compulsive and

Related Disorders

Chapter Overview

This chapter outlines the concept of anxiety, fear, and its related disorders.Anxiety is a future-oriented state characterized by negative affect in which a person focuses on the possibility of uncontrollable danger or misfortune.Fear is a present-oriented mood state characterized by strong urges to escape and a surge of the sympathetic branch of the autonomic nervous system.This chapter provides detailed descriptions of the nature and phenomenology of anxiety and panic attacks, and each of the major anxiety disorders (generalized anxiety disorder, panic disorder and agoraphobia,specific phobias, and social anxiety disorder (social phobia) the trauma-and stressor-related disorders (acute stress disorder and posttraumatic stress disorder), and obsessive-compulsive and related disorders(obsessive-compulsive disorder and body dysmorphic disorder).For each, case examples are provided as well as summaries of symptomatology, course, prevalence, and etiological factors.Psychological and drug treatments are also discussed, along with the diagnostic changes that have occurred in the DSM-5revision and how it will affect our understanding of these disorders moving forward.

Chapter Outline

THE COMPLEXITY OF ANXIETY DISORDERS

Anxiety, Fear, and Panic: Some Definitions

Causes of Anxiety and Related Disorders

Comorbidity of Anxiety and Related Disorders

Comorbidity with Physical Disorders

Suicide

ANXIETY DISORDERS

GENERALIZED ANXIETY DISORDER

Clinical Description

Statistics

Causes

Treatment

PANIC DISORDER AND AGORAPHOBIA

Clinical Description

Statistics

Causes

Treatment

SPECIFIC PHOBIA

Clinical Description

Statistics

Causes

Treatment

SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)

Clinical Description

Statistics

Causes

Treatment

Trauma- and STressor-RElated Disorders

POSTTRAUMATIC STRESS DISORDER

Clinical Description

Statistics

Causes

Treatment

Obsessive-Compulsive and RElated Disorders

OBSESSIVE-COMPULSIVE DISORDER

Clinical Description

Statistics

Causes

Treatment

Body Dysmorphic DISORDER

Plastic Surgery and Other Medical Treatments

Other Obsessive-Compulsive and Related DISORDERS

Hoarding Disorder

Trichotillomania (Hair Pulling Disorder) and Excoriation (Skin Picking Disorder)

Detailed Outline

The Complexity of Anxiety Disorders

Anxiety is a future-oriented state characterized by negative affect in which a person focuses on the possibility of uncontrollable danger or misfortune; in contrast, fear is a present-oriented state characterized by strong and immediate escapist tendencies and a surge in the sympathetic branch of the autonomic nervous system in response to current danger.

A panic attack represents the alarm response of real fear, but there is no actual danger.

Panic attacks may be (1) unexpected (uncued) or (2) expected (cued), the distinction between which is clearly whether or not the context of the attack can be predicted based on past panic experiences.

Panic and anxiety combine to create different anxiety disorders.

 Research evidence exists to support multiple causes of anxiety, including biological models that identify brain circuit and neurotransmitter involvement as well as psychological and social contributions. An integrated model of these factors considers how they all contribute simultaneously to the presence of abnormal, potentially pathological levels of anxiety.

Discussion Point:

How could the “triple vulnerability” theory be used to explain the development of panic disorder?

Be sure that students can generate examples of generalized psychological vulnerability versus specific psychological vulnerability.

ANXIETY DISORDERS

Generalized Anxiety Disorder

In generalized anxiety disorder (GAD), anxiety focuses on minor everyday events, not one major worry or concern.

Both genetic and psychological vulnerabilities seem to contribute to the development of GAD. In particular is the fact that individuals with GAD seem to be more sensitive to threat in general, particularly when the threat has some personal relevance.

Although drug and psychological treatments may be effective in the short term, the most successful long-term treatment may help individuals with GAD focus on what is really threatening to them in their lives. While benzodiazepine medications are useful for an acute, crisis stage of a week or two, recent evidence suggests that antidepressant medications such as Paxil and Effexor provide superior symptoms relief past that initial stage.

Panic Disorder and Agoraphobia

Panic disorder is marked by repeated attacks of debilitating, overwhelming anxiety that is often accompanied by a myriad of physical symptoms. It is sometimes, but not always, accompanied by agoraphobia, (a fear and avoidance of situations considered to be “unsafe”).

Discussion Point:

What is the relationship between agoraphobia and panic disorder? How might these conditions also lead to other comorbid conditions?

This discussion could include how having a panic attack in a situation may make a person feel more vulnerable in that location, which could generalize to other situations as well. Because of agoraphobia, people limit their experiences with the outside world, which prevents them from being able to find out what would happen if they were to confront the fear. Comorbid depression and alcohol and substance use disorders may develop if the person has limited skills for coping with anxiety and distress.

We all have some genetic vulnerability to stress, and many of us have had a neurobiological overreaction to some stressful event—that is, a panic attack. Individuals who develop panic disorder then develop anxiety over the possibility of having another panic attack.

Both drug and psychological treatments have proved successful in the treatment of panic disorder. One psychological method, panic control treatment (PCT), concentrates on exposing patients to clusters of sensations that remind them of their panic attacks. The symptoms of agoraphobia that can accompany panic disorder can be effectively treated with gradual exposure exercises, sometimes combined with anxiety-reducing coping mechanisms. These approaches do not “cure” the issue, however, as the panic attacks may persist and cause ongoing related agoraphobic issues.

Specific Phobia

In phobic disorders, the individual avoids situations that produce severe anxiety, panic, or both. In specific phobia, the fear is focused on a particular object or situation.

Discussion Point:

How might a parent seek to determine if a child’s fears are reasonable, ordinary responses to the world or the beginning of an anxiety disorder?

Discussion Point:

Do you have any severe fears? What would you use as a way of assessing whether that fear is or is not a phobia?

Students should be able to refer back to the discussion of the distinction between normal, abnormal, and pathological and should integrate several of those criteria into their evaluation of what escalates a fear into a phobia. Encourage students to participate only to their own level of comfort and appropriate self-disclosure. The instructor may want to have several hypothetical examples ready in case students are reticent to participate.

Phobias can be acquired by experiencing some traumatic event; they can also be learned vicariously or even be taught.

Treatment of phobias is rather straightforward, with a focus on structured and consistent exposure-based exercises.

Social Anxiety Disorder (Social Phobia)

Social anxiety disorder (SAD)is a fear of being around others, particularly in situations that call for some kind of “performance” in front of other people. The fear often centers around a worry of behaving in some embarrassing or humiliating way that may bring negative judgment from others.

One model for how people acquire SAD suggests that those with the condition may be predisposed to be highly sensitive to negative messages from others, including anger, rejection, and criticism. These signals may be perceived in subtle facial expressions, contributing to the symptoms of the disorder.

Although the causes of SAD are similar to those of specific phobias, treatment has a different focus that includes rehearsing or role-playing socially phobic situations. In addition, drug treatments have been effective.

Selective mutism is a condition now categorized as an anxiety disorder, and is closely related to social anxiety disorder. It involves a lack of speech in situations where speaking is expected, and has a high level of comorbidity with SAD, and the treatment is similar to that of SAD with a greater emphasis on speech.

TRAUMA- AND STRESSOR-RELATED DISORDERS

Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) focuses on avoiding thoughts or images of past traumatic experiences. It is diagnosed when the symptoms emerge more than one month after the traumatic event, or if the symptoms persist for longer than one month. If the symptoms occur within the first month, the diagnosis is acute stress disorder.

The precipitating cause of PTSD is obvious—a traumatic experience. But mere exposure to trauma is not enough. The intensity of the experience seems to be a factor in whether an individual develops PTSD; biological vulnerabilities, as well as social and cultural factors, appear to play a role as well.

Treatment involves reexposing the victim to the trauma and reestablishing a sense of safety to overcome the debilitating effects of PTSD.

Discussion Point:

What are some other challenges a therapist might confront when treating a client for PTSD using imaginal exposure?

Possibilities include a tendency for the client to want to leave therapy, difficulty selecting one event for exposure if the client has had a history of multiple traumas, difficulty getting the client to engage emotionally with the memory, and an increase in anxiety symptoms in early stages of the therapy.

Other conditions that are included trauma and stressor-related disorders are adjustment disorders, attachment disorders, reacting attachment disorder, and disinhibited social engagement disorder.

OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) focuses on avoiding frightening or repulsive intrusive thoughts (obsessions) or neutralizing these thoughts through the use of ritualistic behavior (compulsions).

As with all anxiety disorders, biological and psychological vulnerabilities seem to be involved in the development of OCD.

Drug treatment seems to be only modestly successful in treating OCD. The most effective treatment approach is a psychological treatment, exposure and ritualprevention (ERP). Medication has not been found to be superior to this intervention, either in terms of efficacy or relapse prevention. In very severe cases of OCD that have not responded to other interventions and are causing significant life interruption, psychosurgery may be considered as a last resort.

Body Dysmorphic Disorder

In body dysmorphic disorder (BDD), a person who looks normal is obsessively preoccupied with some imagined defect in appearance (imagined ugliness). It was previously considered a somatoform disorder because of the focus on a “body” issue, but more recently the emphasis on the anxiety caused by the exaggerated or imagined defect has caused it to be recategorized as an anxiety disorder.

Patients suffering from BDD often turn to plastic surgery or other medical interventions, which more often than not increase their preoccupation and distress.

Discussion Point:

How do cultural standards of beauty influence BDD?What other disorders share similarity with BDD, and why might the suicide rate in this disorder be so high?

Other Obsessive-Compulsive and Related Disorders

Hoarding disorder is marked by a compulsive tendency to collect objects – often of no sentimental or material value – and to have tremendous difficulty with discarding any possession, and living with excessive clutter and disorganization, often to dangerous extremes.

Hoarding disorder was previously thought of as an extreme variation of OCD, but has recently been separated into its own diagnosis. Treatments may involve encouraging people to assign numerical values to specific objects, followed by discarding those that fall below a specific value. This can help to reduce anxiety that something truly important will be thrown away.

Trichotillomania (hair pulling disorder) involves pulling out one’s own hair from anywhere on the body, including the head, eyebrows, arms, or other locations. It can lead to great embarrassment as a result of appearance-related issues, along with one going to great lengths to cover up the actions. Research suggests that there may be a genetic mutation that explains many cases of this disorder.

Excoriation (skin picking disorder) is repetitive and compulsive picking on or at one’s skin, which can lead to bruises, scabbing, scarring, and damage.

Both trichotillomania and excoriation were previously labeled as impulse-control disorders, but the anxiety that accompanies the behaviors have caused them to be recategorized in DSM-5. Psychological treatments seem to be the most useful for bringing about improvement in both disorders.

Key Terms

anxiety, 123separation anxiety disorder, 149

fear, 124social phobia, 149

panic, 124posttraumatic stress disorder

panic attack, 124 (PTSD), 155

behavioral inhibition system acute stress disorder, 156

(BIS), 126adjustment disorders, 162

fight/flight system (FFS), 126attachment disorders, 162

generalized anxiety disorderreactive attachment disorder, 163

(GAD), 129disinhibited social engagement

panic disorder (PD), 134 disorder, 163

agoraphobia, 134obsessive-compulsive

panic control treatment disorder (OCD), 163

(PCT), 141obsessions, 163

specific phobia, 143compulsions, 163

blood-injection-injurybody dysmorphic disorder

phobia, 144 (BDD), 168

situational phobia, 144trichotillomania, 172

natural environment phobia,excoriation, 172

145

animal phobia, 145

Ideas for Instruction

1.Activity: Preparedness and the Pathways to Phobic Fear Acquisition.Objects of phobic fear are nonrandomly distributed to objects or situations that were threatening to the survival of the species throughout the course of evolution.This evolutionary perspective is described under the concept of preparedness.That is, we are prepared to more readily associate fear with some objects or situations (e.g., snakes, heights) than others (e.g., pajamas, electrical outlets), even though both may be associated with panic or trauma.Moreover, we know that fears may be acquired via direct conditioning or indirectly through observational learning or information transmission.To illustrate both concepts, have students write down an object or situation that they are particularly afraid of, including what event(s) they think led to the development of this top fear.Then, collect the sheets and categorize and tally the lists (or a representative sample thereof, particularly for large classes) on the board or via overhead.What you should find is that most students report fearing objects or situations that have some prepared evolutionary basis.You should also be able to illustrate that few student can recall actual direct conditioning events to explain how their fears developed and that many may simply say “I can’t remember how my fear started.”This exercise is a good spring board to a discussion of the nature and etiology of phobias, including the relation between phobias and impairment in life functioning.

2.Activity: Demonstrating What Panic Attacks Are Like.This exercise is designed to help students appreciate what it might be like to have breathing difficulties and other autonomic symptoms associated with a panic attack.You will need 4" coffee-stirring straws with a tiny lumen (obtained from restaurants, grocery stores, or your campus food court/cafeteria).Before beginning this exercise, inform students that this activity may lead to shortness of breath and may not be appropriate for those with respiratory difficulties due to colds, asthma, or other problems. Also inform students that this exercise is entirely voluntary, though participation is encouraged. Distribute one straw to each student.While seated, students should practice breathing only through the straw.They should avoid breathing through their noses or around the straw.Have students stand and, while continuing to breathe only through the straw, run in place for five minutes.Discuss the students’ experiences after running.Many find they become so short of breath they cannot continue to exercise as designed.Many will also report feeling light-headed, dizzy, tingly, and some may experience increased perspiration.Explore what it might be like to experience shortness of breath and the related sensations, particularly out of the blue in the course of their daily routine (e.g., going to class, when out on a date, at the library, a party, a movie, driving in a car, to name a few).Could they imagine how a panic attack might follow or coincide with the experience of these kinds of physical symptoms?Finally, it is important to have students understand that panic attacks are often very sudden events and that their physical and psychological experience at the end of the straw exercise would happen much more abruptly during an actual panic attack.I often illustrate the concept of abruptness by asking students whether they have ever been pulled over for speeding.Many students will report yes.I then ask them to imagine how they felt when they looked into their rear-view mirror and saw flashing blue lights and a police car riding their tail.Most report feeling gripped by fear, including a sinking feeling in the stomach, nervousness, and the like.The immediacy of this reaction is analogous to a panic attack.

3.Activity: Demonstration of Graduated Exposure for Phobias or Panic.Students often appreciate being able to see what treatment might look like.Devise a hypothetical hierarchy of exposure for a common specific phobia or for panic disorder.Then, ask for a student volunteer and demonstrate how you would proceed to conduct exposure therapy including the therapist-client issues you would consider as you move up the rungs of the fear hierarchy.

4.Activity: Narrative Therapy and Exposure for PTSD.Students often have a difficult time understanding why one would want to have a patient suffering from PTSD relive memories and emotions associated with their trauma in therapy.Ask students to think about something moderately upsetting that happened in the past month.Stress that you do not want them to select an actual trauma, but instead pick an event that they have thought about and that they feel is not completely resolved in their minds.Have the students write about this event for 10 minutes, describing it in detail, including their reactions, thoughts, and feelings.Do not have the students turn it in, but have them discuss if the experience of writing changed their perception of the event.