Anxiety, Trauma- and Stressor-Related, and Obsessive-Compulsive
Successful treatment may help
and Related Disorders
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 escapist tendencies and a surge in the
sympathetic branch of the autonomic nervous system in response
to current danger.
Panic attack represents the alarm response of real fear, but there is
no actual danger.
- Panic attacks may be
(1) unexpected (without warning)
(2) expected (always occurring in a specific situation).
Panic and anxiety combine to create different anxiety and related
disorders. Several disorders are grouped under the heading Anxiety
Disorders.
ANXIETY DISORDERS
Generalized Anxiety Disorder
- Generalized anxiety disorder (GAD), anxiety focuses on minor,
everyday events and not on one major worry or concern.
- Both genetic and psychological vulnerabilities seem to contribute
to the development of GAD.
Timeline; 6+ months Anxiety Symptoms
Symptoms; Worry, Irritability, Fatigue, Tension, Concentration,
Restlessness this symptoms is NOT associated with the specific
person or event
Treatment; SSRIs, SNRIs, CBT (Cognitive Behavioral Therapy)
- Although drug and psychological treatments may be effective in
the short term, drug treatments are no more effective in the long
term than placebo treatments.
individuals with GAD focus on what is really threatening to them in
their lives.
Diagnostic Criteria for Generalized Anxiety Disorder
A. Excessive anxiety and worry, occurring more days than not for at
least 6 months about a number of events or activities
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with at least three (or more)
of the following six symptoms;
1. Restlessness or feeling keyed up or on edge
2. Being easily fatigued
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance (difficulty falling or staying asleep or restless,
unsatisfying sleep)
D. The anxiety, worry or physical symptoms cause clinically
significant distress or impairment in social, occupational, or other
important areas of functioning.
E. The disturbance is not due to the direct physiological effects of a
substance or a general medical
F. The disturbance is not better explained by another mental
disorder.
Panic Disorders and Agoraphobia
- In panic disorder, which may or may not be accompanied by
agoraphobia (a fear and avoidance of situations considered to be
“unsafe”), anxiety is focused on the next panic attack. For some
people, agoraphobia develops in the absence of panic attacks or
panic-like symptoms.
- 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 and
then develop anxiety over the possibility of having another panic
attack.
Timeline; 1+ months
Symptoms; Panic “attacks” ( palpitations, SOB, impending doom,
tachycardia) Fear, worry or behavioral change related to another
attack
Treatment; Maintenance: SSRIs/SNRIs + CBT Abortive:
Benzodiazepine
- Both drug and psychological treatments have proved successful in
the treatment of panic disorder. One psychological method, panic
control treatment, concentrates on exposing patients to clusters of
sensations that remind them of their panic attacks. For
agoraphobia, therapeutically supervised exposure to feared
situations is most effective.
Diagnostic Criteria for Panic Disorder
A. Recurrent unexpected panic attacks are present.
B. At least one of the attacks has been followed by 1 month or more
of one or both of the following:
(a) Persistent concern or worry about additional panic attacks or
their consequences
(b) A significant maladaptive change in behavior related to the
attacks
C. The disturbance is not attributable to the physiological effects of a
substance or another medical condition
D. The disturbance is not better explained by another mental
disorder (e.g., the panic attacks do not occur only in response to
feared social situations, as in social anxiety disorder).
Diagnostic Criteria for Agoraphobia
A. Marked fear or anxiety about two or more of the following five
situations: Public transportation, open spaces, enclosed places,
standing in line or being in a crowd, being outside the home alone.
B. The individual fears or avoids these situations due to thoughts
that escape might be difficult or help might not be available in the
event of developing panic-like symptoms or other incapacitating or
embarrassing symptoms
C. The agoraphobic situations almost always provoke fear or
anxiety.
D. The agoraphobic situations are actively avoided, require the
presence of a companion, or are endured with intense fear or
anxiety.
E. The fear or anxiety is out of proportion to the actual danger posed
by the agoraphobic situations, and to the sociocultural context.
F. The fear, anxiety or avoidance is persistent, typically lasting for 6
months or more.
G. The fear, anxiety or avoidance causes clinically significant distress
or impairment in social, occupational or other important areas of
functioning.
H. If another medical condition is present, the fear, anxiety or
avoidance is clearly excessive.
I. The fear, anxiety or avoidance is not better explained by the
symptoms of another mental disorder and are not related exclusively
to obsessions reminders of traumatic events or fear of separation.
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.
- Phobias can be acquired by experiencing some traumatic event;
they can also be learned vicariously or even be taught.
Timeline; 6+ months
Symptoms; Instense fear of specific object | Almost always ego-
dystonic
Treatment; Systemic Desensitization
- Treatment of phobias is rather straightforward, with a focus on
structured and consistent exposure-based exercises.
Diagnostic Criteria for Specific Phobia
A. Marked fear or anxiety about a specific object or situation
B. The phobic object or situation almost always provokes immediate
fear or anxiety.
C. The phobic object or situation is actively avoided or endured with
intense fear or anxiety.
D. The fear or anxiety is out of proportion to the actual danger
posed by the specific object or situation, and to the sociocultural
context.
E. The fear, anxiety or avoidance is persistent, typically lasting for 6
months or more.
F. The fear, anxiety, or avoidance causes clinically significant distress
or impairment in social, occupational or other important areas of
functioning.
G. The disturbance is not better explained by the symptoms of
another mental disorder, including fear, anxiety and avoidance of:
situations associated with panic-like symptoms or other
incapacitating symptoms, objects or situations related to obsessions,
reminders of traumatic events, separation from home or attachment
figures, or social situations.
Specify type:
1. Animal
2. Natural environment (e.g., heights, storms, and water)
3. Blood–injection–injury
4. Situational (e.g., planes, elevators, or enclosed places)
5. Other (e.g., phobic avoidance of situations that may lead to
choking, vomiting, or contracting an illness; or in children, avoidance
of loud sounds or costumed characters)
Social Anxiety Disorder (Social Phobia)
- Social anxiety disorder is a fear of being around others, particularly
in situations that call for some kind of “performance” in front of
other people.
- Although the causes of social anxiety disorder 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.
- Several disorders are also grouped under the heading Trauma- and
Stressor-Related Disorders
Diagnostic Criteria for Social Anxiety Disorder (Social Phobia)
A. Marked fear or anxiety about one or more social situations in
which the person is exposed to possible scrutiny by others. Examples
include social interactions being observed or performing in front of
others.
B. The individual fears that he or she will act in a way, or show
anxiety symptoms, that will be negatively evaluated.
C. The social situations almost always provoke fear or anxiety.
D. The social situations are avoided or endured with intense fear or
anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed
by the social situation, and to the sociocultural context.
F . The fear, anxiety or avoidance is persistent, typically lasting for 6
months or more.
G. The fear, anxiety or avoidance causes clinically significant distress
or impairment in social, occupational or other important areas of
functioning.
H. The fear, anxiety or avoidance is not attributable to the effects of
a substance or another medical condition.
I. The fear, anxiety or avoidance is not better explained by the
symptoms of another mental disorder, such as panic disorder or
separation anxiety disorder.
J. If another medical condition is present, the fear, anxiety or
avoidance is clearly unrelated or is excessive.
Specify if:
Performance only: If the fear is restricted to speaking or performing
in public.
TRAUMA- AND STRESSOR-RELATED DISORDERS
Posttraumatic Stress Disorder
Potential life threat -> Trauma symptoms -> How long?
- Posttraumatic stress disorder (PTSD) focuses on avoiding thoughts
or images of past traumatic experiences.
- 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.
Timeline;
(1) less than 1 month of symptoms - acute stress disorder
(2) more than 1 month of symptoms – PTSD
Treatment; Maintenance: SSRIs, theraphy and Symptomatic:
Prezosin (for nightmares specifically if the core component or the
core symptom are nightmares.
- Treatment involves reexposing the victim to the trauma and
reestablishing a sense of safety to overcome the debilitating effects
of PTSD.
Diagnostic Criteria for Posttraumatic Stress Disorder
A. Exposure to actual or threatened death, serious injury, or sexual
violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as they occurred to others.
3. Learning that the event(s) occurred to a close relative or close
friend. In cases of actual or threatened death of a family member or
friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of
the traumatic event(s).
B. Presence of one (or more) of the following intrusion symptoms
associated with the traumatic event(s), beginning after the
traumatic event(s) occurred;
1. Recurrent, involuntary and intrusive distressing memories of the
traumatic event(s).
2. Recurrent distressing dreams in which the content and/or affect
of the dream are related to the traumatic event(s).
3. Dissociative reactions (e.g., flashbacks) in which the individual
feels or acts as if the traumatic event(s) were recurring.
4. Intense or prolonged psychological distress at exposure to
internal or external cues that symbolize or resemble an aspect of
the traumatic event(s).
5. Marked physiological reactions to internal or external cues that
symbolize or resemble an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic
event(s), beginning after the traumatic event(s) occurred, as
evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts,
feelings, or conversations about or closely associated with the
traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people,
places, conversations, activities, objects, situations) that arouse
distressing memories, thoughts, or feelings about or closely
associated with the traumatic event(s).
3. Inability to recall an important aspect of the trauma
4. Markedly diminished interest or participation in significant
activities
5. Feeling of detachment or estrangement from others
6. Restricted range of affect
7. Sense of a foreshortened future
D. Negative alterations in cognitions and mood associated with the
traumatic event(s), beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the traumatic
event(s).
2. Persistent and exaggerated negative beliefs or expectations about
oneself, others, or the world
3. Persistent distorted cognitions about the cause or consequences
of the traumatic event(s) that lead the individual to blame
himself/herself or others.
4. Persistent negative emotional state
5. Markedly diminished interest or participation in significant
activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions
E. Duration of the disturbance (Criteria B, C, D and E) is more than
one month.
F . The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
Specify if:
With delayed expression: If the diagnostic threshold is not exceeded
until at least 6 months after the event (although it is understood
that onset and expression of some symptoms may be immediate).
Specify if:
With Dissociative Symptoms: The individual’s symptoms meet the
criteria for posttraumatic stress disorder, and in addition, in
response to the stressor, the individual experiences persistent or
recurrent symptoms of depersonalization or derealization.
Adjustment Disorders
- Adjustment disorder is the development of anxiety or depression in
response to stressful, but not traumatic, life events.
- Individuals prone to anxiety or depression generally may
experience increases during stressful life events.
- Trigger -> Mood Symptoms -> Up to 6 months
> Some triggering events happens causes mood symptoms.
> If the event and the subsequent mood symptoms have only lasted
up to six months, meaning basically up to the last day of the fifth
month.
Timeline; 0-5 months of Anxiety Symptoms - follows up specific
event
Symptoms; Worry, Irritability, Fatigue, Tension, Concentration,
Restlessness this symptoms
Treatment; CBT (Cognitive Behavioral Therapy), SSRIs, SNRIs
Attachment Disorders
- Children experiencing inadequate, abusive, or absent caregiving in
early childhood fail to develop normal attachment relationships with
caregivers, resulting in two different disorders.
- Reactive attachment disorder describes children who are inhibited
and emotionally withdrawn and unable to form attachment with
caregivers.
– Disinhibited social engagement disorder describes children who
inappropriately approach all strangers, behaving as if they had
always had strong loving relationships with them.
- Several disorders are grouped under the heading of Obsessive
Compulsive and Related Disorders.
OBSESSIVE-COMPULSIVE AND RELATED DISORDERS
Obsessive-Compulsive Disorder
Intrusive Idea (obsession) -> Distress -> Repetitive Rituals (compulsion)
- ego-dystonic (person is aware and struggle with it)
- 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 called exposure and ritual prevention (ERP).
Body Dysmorphic Disorder
- In body dysmorphic disorder (BDD), a person who looks normal is
obsessively preoccupied with some imagined defect in appearance
(imagined ugliness).
These patients typically have more insight into their problem and
may seek out plastic surgery as a remedy.
- Psychological treatment approaches are also similar to those for
OCD and are approximately equally successful.
Other Obsessive-Compulsive and Related Disorders
Hoarding Disorder
- Hoarding disorder is characterized by excessive acquisition of
things, difficulty discarding anything, and living with excessive
clutter under conditions best characterized as gross disorganization.
- Treatment approaches are similar to those for OCD but are less
successful
Trichotillomania (Hair Pulling Disorder) and Excoriation (Skin Picking
Disorder)
- Repetitive and compulsive hair pulling resulting in significant
noticeable loss of hair or repetitive and compulsive picking of the
skin leading to tissue damage characterize trichotillomania and
excoriation disorders respectively
Treatment;
(1) Maintenance: cbt
(2) Symptomatic: Clomipramine, N-acetylcysteine, Zyprexa
Diagnostic Criteria for ObsessiveCompulsive Disorder
A. Presence of obsessions, compulsions or both:
Obsessions are defined by
1. Recurrent and persistent thoughts, urges, or images that are
experienced.
2. The individual attempts to ignore or suppress such thoughts,
impulses, or images, or to neutralize them with some other thought
or action.
Compulsions are defined by
1. Repetitive behaviors or mental acts that the individual feels
driven to perform in response to an obsession, or according to rules
that must be applied rigidly
2. The behaviors or mental acts are aimed at preventing or reducing
distress or preventing some dreaded event or situation.
B. The obsessions or compulsions are time-consuming or cause
clinically significant distress or impairment in social, occupational or
other important areas of functioning.
C. The disturbance is not due to the direct physiological effects of a
substance or another medical condition.
D. The disturbance is not better explained by the symptoms of
another mental disorder.
Specify if:
With good or fair insight: the individual recognizes that obsessive-
compulsive disorder beliefs are definitely or probably not true or
that they may or may not be true.
With poor insight: The individual thinks obsessivecompulsive
disorder beliefs are probably true.
With absent insight/delusional: the person is completely convinced
that obsessive-compulsive disorder beliefs are true.
Specify if:
Tic-related: The individual has a current or past history of a tic
disorder.