CHAPTER 6 ANXIETY,OBSESSIVECOMPULSIVE, AND TRAUMA-RELATED DISORDERS

Source:Figure created by OUP reflecting information found in Diagnostic and Statistical Manual of Mental
Disorders, fifth edition (DSM-5). 2013.
UNDERSTANDING PSYCHOPATHOLOGY

Neurotic,stress-related a nd somatoform disorders

Reaction Ib severe

Phobicanxiety disorders Other arxiety disorders

disorder
UNDERSTANDING PSYCHOPATHOLOGY
Figure 6.2:The World Health Organization ICD-10 categorises phobic anxiety disorders, other anxiety disorders, obsessive-
compulsivedisorder, reaction to severe stress,and adjustment disorders as shown above.

Source: Intemational Statistical Classification of Diseases and Related Health Problems,tenth revision (ICD-10).2016.
202 of 715 TER 6 ANXIETY, OBSESSIVE-COMPULSIVE,
AND TRAUMA-RELATED DISORDERS

Figure 6.3: The World Health Organization proposed ICD-11 categorises anxiety or fear-related
disorders,obsessive-compu Isiveand related disorders, and disorders specifically related to stress as shown
above.
202 of 715 TER 6 ANXIETY, OBSESSIVE-COMPULSIVE,
AND TRAUMA-RELATED DISORDERS
Source:International Classification of Diseasesfor Mortalty and Morbidity Statistics. eleventh revision (ICO-11).
2018
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INTRODUCTION

The word'anxiety' originates from the Latin anxietas, meaning to choke,throttle,and upset,and it is
frequently used in everyday language to refer to an emotion that is evoked in a wide range of situations.
Many communities around the world are plagued with the reality of crime,terrorism, motor vehicle
accidents, natural disasters, and other potential threats that create a social climate of fear and anxiety. More
commonly, anxiety develops as a result of everyday pressures such as finances, relationship stressors, work-
related pressures, etc.

The South African Stress and Health Study (SASH) identified anxiety disorders as the most
prevalent class of mental disorders in South Africa (8.1%), with panic disorder having the
greatest number of severe cases (66%) (Herman et al., 2009). Anxiety is also used to describe a
specific cluster of disorders that share core features of excessive fear and anxiety,and related
behavioural disturbances (American Psychiatric Association, 2013). People with anxiety
disorders describe a sense of worry that is either present most of the time, or only present in
specific situations. Anxiety encompasses physiological,cognitive,affective,and behavioural
responses. When an individual is in an anxiety-provoking situation, the autonomic nervous
system induces physiological arousal that is characterised by sweating,palpitations, headache,
shortness of breath, and tachycardia (rapid heart rate). This reaction results in negative
cognitions (thoughts), unpleasant feelings, and tension, and a feeling of apprehension or
foreboding. Once this reaction has been induced, the individual prepares to either confront or
avoid the situation.
Research suggests that most anxiety disorders have an earlier age of onset compared to many other
classes of psychiatric disorders. They have been found to be more prevalent in females than males, with the
prevalence rate being twice as high in females. The median age of onset varies between specific anxiety
disorders. Anxiety symptoms are widespread across communities, and they have high frequency in the global
population. In the short term,anxiety can help drive performance, but ifexcessive and persistent, it can have
a potentially substantial negative impact on an individual's functioning.

Anxiety disorders can present alone but they are often comorbid with other mental and medical
conditions,and they may also be comorbid among themselves. The association between anxiety and pain
has been documented extensively, as physical symptoms are exacerbated by anxiety or are comorbid with
anxiety disorders (Jordan & Okifuji, 2011).Somatic complaints (physical symptoms) are a common feature of
anxiety disorders and may include gastrointestinal symptoms, headaches, and muscle tension. They may
also lead to substance use.

The coexistence of anxiety and depressive disorders has been extensively recorded in
literature and is a common presentation in clinical practice. Studies indicate that up to 70%of
people with depressive disorders also have comorbid anxiety symptoms, with 40% to
70%simultancously meeting the criteria for at least one type of anxiety disorder (Zhiguo &
Fang,2014).The comorbidity of these two disabling conditions presents a treatment challenge in
that individuals are more functionally impaired than those who present with either disorder
alone.
There is a distinction between state anxiety, trait anxiety, and anxiety disorders (Perez-Edgar & Fox,
2005).State anxiety refers to a measure of an individual's immediate or acute level of anxiety,whereas trait
anxiety refers to the long-term tendency of an individual to show anxiety responses to environmental events.
At the other end of the spectrum lie
 CHAPTER 6 ANXIETY,OBSESSIVE-COMPULSIVE, AND TRAUMA-RELATED DISORDERS

anxiety disorders; these are disabling and limit an individual's ability to engage freely and
effectively with their environment. The distinction between state and trait anxiety,and anxiety
disorders, is in the degree of functional impairment that results (Perez-Edgar &Fox, 2005).
Based on the commona lity between theirneurobiological,genetic, and psychological
features, anxicty disorders are split into three categories in the DSM-5:
anxicty
obsessive-compulsive and related disorders
trauma-and stressor-related disorders.

Selective mutism and separation anxiety disorder are currently classified with 'other anxiety
disorders' whereas, in the DSM-IV, they were included in the disorders diagnosed in
infancy.childhood,and adolescence.

FEAR, ANXIETY, STRESS, AND WORRY

The DSM-5 distinguishes between fear,anxiety,stress,and worry.These terms will be discussed
inthis section.

Fear
Fear is a commonly experienced and basic emotion felt by all species. It is defined as an emotiona
I response to real or perceived imminent threat (American Psychiatric Association,2013). It is not
necessarily unreasonable or unwarranted.In fact, in many instances, the experience of fear helps
us to survive by assisting us to respond to actual threats in our environment.When faced with a
threat, our priority is to escape that threat,or to fight,if escape is not an option. This reaction is
associated with autonom ic arousal that is necessary for the 'fight-or-flight' reaction,which is the
body's physiological response to fear. In the world we live in today,we are often faced with threats
of possible future harm. It is unfortunate that violent crime,personal injury, and traumatic
exposure have become a part of our daily reality.
Fear is a response to an immediate threat,and this distinguishes it from anxiety.Anxiety is an
emotion that is associated with worrying about future events that may or may not happen,such as
whether one will cope under a particular set of circumstances,and worrying about interpersonal
difficulties or specific upcoming events.

Anxiety
As a system that helps us prepare for the future, anxiety is functional and adaptive at a normative
level.Many pople experience anxiety in different ways,with different durations and degrees of
intensity. It allows people to ready themselves to face future situations,and the continuum
between worry, anxiety,and panic operates as an alarm system that is aimed at protecting us from
harm. Using information gathered from our past experiences helps us to avoid certain
consequences or to brace ourselves in certain situations.
UNDERSTANDING PSYCHOPATHOLOGY

When we are unable to preparefor thefuture inan effective and efficient manner,this results in
uncertainty,which contriutes to anxiety (Grupe &Nitschke,2013).Asexplained byMeyerbroker and Powers
(2015), when this system is triggered even in relatively safe environments, it can result in us fearing the alarm
system itself,which can be disabling.Pathological anxiety results when our danger detection system is triggered
in a non-adaptive way.

Cognitive theory describes a 'catastrophic cognition' as a primary mechanism for anxiety

disorders. This model proposes the misinterpretation of bodily sensations, which gives rise to
bodily arousal, resulting in a panic attack (Beck & Emery, 1985; Clark, 1986). These catastrophic
cognitions (thoughts) include physical, emotional,mental,behavioural,and social catastrophes
(Austin & Richards,2001).

Stress
Stress is a common occurrence and is synonymous with the lives that many people leadtoday.During
periods of stress, bodily systems are put under strain in order to cope with excessive demands in the
environment. At times,people are able to manage their stress and continue to live healthy lives in spite of
their stressors. Stressors are perceived as qualitatively positive or negative. The effects of negative events
can lead to physical illness and psychological disorders such as anxiety disorders, mood disorders, substance
abuse, or physical illness.Stress often has a negative effect on quality of life, resulting in weight
changes,insomnia,changes in mood, and mental fatigue.

The General Adaptation Syndrome (GAS) is a three-stage process that refers to the different
stages of stress that the body goes through during a stressful reaction.Fear and the 'alarm
response' are considered to be the first phase of the stress response. This involves the 'fight-or -
flight' reaction during which the body prepares to fight or to flee from a pereeived dangerous
situation. During this phase,the body releases adrenalin,the heart rateincreases,and the adrenal
glands release cortisol. Phase iwo is called the 'resistance stage'. During this stage,certain coping
actions occur, and these are aimed at returning the body to its pre-stress state.During the
resistance stage,the body repairs itself by normalising the functions that were elevated during the
alarm response stage. The final stage, called the 'exhaustion stage: occurs when the resistance
stage is continuous and prolonged, and it can result in chronic stress.This can have a negative
impact on the immune system, resulting in physical illness.It can also lead to psychological distress.

Worry
The term 'worry' is also mentioned in the DSM-5, referring to the cognitive aspects of apprehensive
expectation (American Psychiatric Association,2013).

HISTORY OF ANXIETY AND PANIC DISORDERS

In the second half of the 1800s and the early 1900s,the Austrian neurologists Sigmund Freud and
Moritz Benedikt, the German psychiatrist Carl Friederich Otto Westphal, and the French
psychotherapist Pierre Janet all made contributions to this emerging field. Freud
 6 ANXIETY,OBSESSIVE-COMPULSIVE, AND TRAUMA-RELATED DISORDERS

proposed that anxiety is caused by defence mechanisms that are triggered in response to threatening
impulses. Benedikt described a condition he called 'platzschwindel' ('place dizziness') (Balaban & Jacob,
2001:Hinton, Nathan, Bird,& Park, 2002),which Westphal then termed 'agoraphobie'and which we now
call agoraphobia (Callard, 2006; Sinnott, Jone s,& Fordham,1981). probably from the Greek words
for'open space' and 'fear'. Westphal also described how obsessive images could overcome the will of a
sane and insightful person,contributing to research on what later became known as obsessive-
compulsivedisorder(De Haan et al.,2013).Janet studied the relationship between memory and trauma.
The emergence of PTSD as a clinical diagnosis resulted from observations made of the
psychological distress incurred by combatants and concentration camp survivors of World Wars I and
II. Following this,the negative impact of traumatic exposure related to other life stressors also received
growing recognition in rescarch literature in later years.
A lot of the discussion around anxiety and panic disorders surrounded the presence or absence of
cues,and what did,or did not,constitute a distinct disorder. For example.in 1980, the DSM-III recognised
panic disorder without agoraphobia and panic disorder with agoraphobia as distinct disorders. In the
DSM-5, the anxiety disorders,the obsessive-compulsive and related disorders, and the trauma- and
stressor-related disorders were considered distinct enough to be placed in three separate chapters. The
ICD-10 instead uses four categories,because it makes a distinction between the more specific 'phobic
anxicty disorders' and the more general 'other anxiety orders'.However,the ICD-11 has three sets of
disorders,which are very similar to the DSM-5 categories.

Figure 6.4: The Scream (1895) by Voyiya was inspired by a South African man Figure 6.5: Black and
Blue 1 by Vuyile Edvard Munch is seen as an early who had been beaten by the apartheid
depiction of anxiety experienced by regime, and continued to try to fend off the artist when outside
in nature. attackers even when no one was there.
UNDERSTANDING PSYCHOPATHOLOGY

ACTIVITY
Compare the two artworks that both show people who suffer from disorders described in this
chapter.How are they similar? How are they different?

ANXIETY DISORDERS

Separation anxiety disorder

Individuals who experience separation anxiety disorder (see also Chapter 15) have inappropriate and
excessive worry about being separated from their home, or from significant attachment figures. This
results in significant distress when the individual faces the prospect of,or has the experience of, leaving
a significant attachment figure, which is often followed by excessive worry about losing the attachment
figure through injury,illess or other forms of harm. The individual may refuse or be reluctant to leave
the home as a result of this excessive worry.As a result,symptoms of separation anxiety often lead to
significant distress in daily functioning and may also result in somatic (physical)complaints,which often
present when separation is anticipated or experienced (American Psychological Association,2013),as
well as nightmares involving the theme of separation.

The restructuring of some sections of the DSM-5 brought about a reclassification of separation
anxiety disorder into the anxiety disorders category. In previous versions of the DSM,this disorder was
listed under the section 'disorders usually first diagnosed in infancy,childhood,or adolescence'. This wa
because this disorder was considered to typically develop in childhood,and was diagnosed in adults only
if the onset was before I8yearsof age. Although the vast majority of diagnoses are made during
childhood, the current classification acknowledges that separation anxiety disorder may be diagnosed
throughout the entire lifespan.Therefore,even if appearing in childhood,separation anxiety disorder
may persist into adulthood.

Specific phobias
Fear is understood as an adaptive and healthy response to environmental threats and,as discussed
earlier, it is a useful response that prepares individuals to respond to threatening stimuli in their
immediate environment.When there is an extreme manifestation of fear towards objects or situations
in the absence of danger that warrants such fear,the fear may be described as maladaptive.

Specific phobia (previously referred to as 'simple phobia') is marked by persistently excessive or

unreasonable fear when anticipating,or in the presence of, a specific object or situation. When
individuals with specific phobia encounter the feared object or situation,they may experience intense
fear or anxicty,which may also result in a panic attack. The fear or anxiety frequently results in
avoidance bchaviour, or it is endured with extreme discomfort or dread.
 CHAPTER 6 ANXIETY, OBSESSIVE-COMPULSIVE, AND TRAUMA-RELATEDDISORDERS

To varying degrees, specific phobia may cause an individual to lead a restricted lifestyle,and it
can have a significant impact on quality of life. Examples of specific phobias include animal phobias
such as fear of dogs or spiders, or blood-injection-injury phobias such the fear of injections or being
close to needles. This condition frequently emerges in childhood,with a mean onset of beteen the
ages of seven and nine. Specific phobias tend to persist for several years and they are strongly
predictive of anxiety and mood disorders,as well as substance use disordes (Eaton, Bienvenu, &
Miloyan, 2018).
Early discussions about the actiology of specific phobias attributed these conditions to
evolution,in that the feared stimuli reflected the dangers of our prehistoric environment.The fear
of these evolutionary dangers became genetically encoded as a result of natural
selection.Conseque ntly,people would still possess the innate fear of certain stimuli;for example,a
fear of heights may cause someone to drive long distances in order to avoid flying.However,in other
cases,people develop adaptive mechanisms to certain fears;for example,air crew may be trained to
experience less anxiety when flying.

Figure 6.6:People with needle-related fear and needle phobia tend to have extreme vasovagal
responses (sudden, rapid drop in heart rate and blood pressure,often resulting in fainting.) This
 CHAPTER 6 ANXIETY, OBSESSIVE-COMPULSIVE, AND TRAUMA-RELATEDDISORDERS

condition (also known as trypanophobia), affects an individual'sfunctioning. It may result in

avoidance of healthcare settings.
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Table 6.1: Diagnostic criteria for specific phobia from the DSM-5 and ICD-10

A. Marked fear or anxiety about a specific object or A disorder in which anxiety is situation (e.g.flying.heights, animals, receiving an
provoked only,or predominantly.injection,seeing blood) in certain highly specific situations.

Note:In children, the fear or anxiety may be expressed by crying,tantrums,freezing.or clinging.

These situations may include B. The phobic object or situation almost always proximity to particular animals.provokes immediate fear
or anxiety. heights,thunder. darkness.flying. closed spaces.

C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.

The specific phobic object or D. The fear or anxiety is out of proportion to the actual situation is the characteristically danger posed by the phobic
object or situation and avoided or endured with dread.to the socioculturalcontext.

The triggering situation is often discrete.

E. The fear, anxiety.or avoidance is persistent. typically lasting for six months or more.

Contact with the triggering F. The fear,anxiety, or avoidance causes clinically situation can evoke panic significant distress or impairment in
social, attacks.occupat ional, or other important areas of functioning.

G. The disturbance is not better explained by symptoms of another mental disorder.including fear,anxiety.or avoidance of situations associated with
panic-like symptoms or other incapacitatingsymptoms (as in agoraphob ia): objects or situations related to obsessions (as in obsessive-compulsive
disorder).separation from home or attachment figures (as in separation anxiety disorder) or social situations (as in social anxiety disorder).

Source:Reprinted with permission from the Diagnostic and Statistcal Manual of Mental Disorders,fifth edition (DSM-5). American
Psyct1iatric Association (APA).2013.p.197,and the ICD-1O Classification of Mental and Behavioural Disorders: Diagnostic Criteria for
Research, World Healt1 Organization(WHO).Geneva,2007.

Panic disorder
Panic disorders werefirst included in the DSM-III,where theywere described as spontaneous episodes of intense anxiety.Panic disorder is represented by
recurrent (i.e. more than one).unexpected panic attacks (i.e.there is no obvious cue or trigger at the timeof the occurrence).Panic attacks are a particular
type of fear response, and they occupy a prominent space in the anxiety disorders cluster(Hanson & Modiba, 2017). The DSM-5 defines a panic atack as
an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes.and during which time there is the presence of four or more of
a list of 13 somatic(physical)and cognitive symptoms.

Following at least one attack,there is a period of at least one month (or more) where the individual worries that another attack may occur and/or
the attack may be followed by a
 CHAPTER 6 ANXIETY,OBSESSIVE-COMPULSIVE,AND TRAUMA-RELATED DISORDERS

pattern of maladaptive behaviours related to the attacks.The symptoms of panic attacks are provoked unexpectedly and
have no obvious trigger. Panic disorder is said to affect 3% to 4% of the general population and is most prevalent in women.
Panic attacks are not limited to anxiety disorders and can also feature in other mental disorders.

Table 6.2:Diagnostic criteria for panic disorder from the DSM-5 and ICD-10

Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a
peak within minutes, and during which time four (or more) of the following symptoms occur:

Note: the abrupt surge can occur from a calm state or an anxious state.

(1) Palpitations, pounding heart,or accelerated heart rate.

(2) Sweating.

(3) Trembling or shaking.

The essential feature Is recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set
of circumstances and are therefore unpredictab le.As with other anxiety disorders, the dominant symptoms include sudden
onset of palpitations,chest pain, choking sensations,dizziness,and feelings of unreality (depersonalisation or derealisation).
There is often also a secondary fear of dying,losing control, or going mad. Panic disorder should not be given as the main
diagnosis if the patient has a depressive disorder at the time the attacks start; in these circumstances the panic attacks are
probably secondary to depression.

(4)Sensations of shortness of breath or smothering.

(5) Feelings of choking.

(6) Chest pain or discomfort.

(7) Nausea or abdominal distress.

(8) Feeling dizzy. unsteady,light-headed,or faint.

(9) Chills or heat sensations.

(10) Paresthesias (numbness or tingling sensations).

(11) Derealisation (feelings of unreality) or

depersonalisation (being detached from onesel.

(12) Fear of losing control or 'going crazy'.

(13)Fear of dying.

Note:Culture-specific symptoms (e.g.tinnitus.neck soreness, headache,uncontrollable screaming or crying) may be seen.

Such symploms should not count as one of the four required symptoms.

B. At least one of the attacks has been followed by one month(or more) of one of the following:

(1) Persistent concern or worry about additional panic attacks or their consequences (e.g.losing control, having a heart
attack, 'going crazy').
 CHAPTER 6 ANXIETY,OBSESSIVE-COMPULSIVE,AND TRAUMA-RELATED DISORDERS

(2) A significant maladaptive change in behaviour related to the attacks (e.g.behaviours designed to avoid having panic
attacks, such as avoidance of exercise or unfamiliar situations).

C. The disturbance is not attributable to the physiological effects of a substance (e.g.a drug of abuse, a medication) or
another medical condition (e.g. hyperthyroidism, cardiopulmonary disorders).
UNDERSTANDING PSYCHOPATHOLOGY

D.The disturbance is not better explained by another

mental disorder (e.g. panic attacks do not occur
only in response to feared social situations, as in
social anxiety disorder,in response to circumscnibed

phobicobjects or situations, as in specific phob ia; in

response to obsessions,as in obsessive-compulsive
disorder; in responseto reminders of traumatic
events, as in posttraumatic stress disorder,or in
response to separation from attachment figures, as in
separation anxiety disorder).

Source: Reprinted with permission from the Dragnostic and Statistical Manual of Mental D sorders.fifth editon (DSM-
5), American Psychiatric Associaiton (APA.) 2013.p. 208. and the ICD-10 International Statistical Classification of
Disease and Related Disorders, World Health Organization (WHO) Geneva, 2016

Agoraphobia
The term 'agoraphobia' stems from the Greek 'agora' which refers to large, open spaces,such as
marketplaces. The classic description of agoraphobia is credited to C. F. Westph al,who, in the 1800s,
described it as a phobia of large, open spaces. This paved the way for what became described in literature
as a common and upset ting phobic disorder(Wittchen,Gloster,Beesdo-Baum, Fava, & Craske, 2010).
Agoraphobia is marked by intense fear or anxiety that is triggered by real or anticipated exposure to a wide
range of situations.The classification of agoraphobia as a primary diagnosis, with or without recurrent panic
attacks,was included in the DSM-III and,since its publication in 1980, agoraphobia has gained much
attention. In the DSM-IV-TR, panic disorder was diagnosed with or without agoraphobia,and agoraphobia
without history of panic disorder.

Table 6.3: Diagnositc criteria for agoraphobia from the DSM-5 and ICD-10

(3)Being in enclosed places (e.g

shops,theatres,cinemas).
(4) Stand ing in line or being in a
A. Marked fear or anxiety about two (or more) of the following crowd.
five situations:
(5) Being outside of the home alone.
(1) Using public transportation (e.g. automobiles.buses, trains,
ships, planes).
(2) Being in open spaces (eg.parking
lots.marketplaces,bridges).
UNDERSTANDING PSYCHOPATHOLOGY

The essential feature is recurrent attacks of severe anxiety

(panic).
The panic attacks are not restricted to any particular situation
or set of circumstances and are thereforeunpredictable.
The dominant symptoms include:
sudden onset of palpitations.
chest pain,choking
sensations, dizziness,
and feelings of unreality
(depersonalisation or
derealisation).
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CHAPTER 6 ANXIETY,OBSESSIVE-COMPULSIV,EAND TRAUMA-RELATED DISORDERS

B.The individual fears or avoids these situations

because of thoughts that escape might be difficult

or help might not be available in the events

of developing panic-like symptoms or either

incapacitating or embarrassing symptoms (e.g.fear

of falling in the elderty;fear of incontinence).

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 situation and to

the sociocultural context.

There is often a secondary fear of
F. The fear,anxiety,or avoidance is persistent,typically
dying,losing control.or goi mad.
lasting six 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 anothermedical condition (e.g. inflammatory bowel

disease, Parkinson's disease) is present, the fear.

anxiety,or avoidance is clearly excessive.

1. The fear,anxiety,or avoidance is not better explained

by the symploms of another mental disorder-for

example,the symptoms are not confined to specific

phobia,situational type;do not involve only social

situations (as in social anxiety disorder) and are not

related exclusively to obsessions (as in obsess ive-

compulsiv e disorder). perceived defects or flaws

 in physical appearance (as in body dysmorphic

disorder).remindersol traumaticevents (as in

posttraumatic stress disorder), or fear of separation

(as in separation anxiety disorder).

Note: Agoraphobia is diagnosed irrespective of

the presenceof panic disorder.If an individual's

presentation meets criteria for panic disorder and

agoraphobia,both diagnoses should be assigned.

Source: Reprinted with permission from the Dagnostic and Statistical Manual of Mental Dsorders.fifth edition (DSM-5).American Psychiatric
Associaiton (APA), 2013. p. 217, and the ICD-1o International Statistical Classification of Disease and Related Disorders. Wold Heath
Orgatzation(WHO). Geneva, 2016.

Social anxiety disorder (social phobia)

In the DSM-5,social anxiety disorder has been recognised as the principal name for the diagnosis,where previous versions of the DSM named
this diagnosis 'social phobia'.This change was intended to convey the pervasiveand significant impairment that results from
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the disorder.The DSM-5 recognises that the fear felt by people with social anxiety disorder is out of proportion to the actual threat,and it should represent
a deviation in terms of the individuaI's cultural context.

Social anxiety disorder frequently emerges during adolescence or early adulthood,and involves excessive and persistent fear of negative evaluation
in social and/or performance situations. According to the DSM-5 criteria for social anxicty disorder, the feared social situation must almost always provoke
fear and anxiety,and thesituation is avoided or endured with fear and anxiety. The individual fears facing possible serutiny by others due to fears that he
or she may behave in ways that will be negatively evaluated, resulting in rejection.

Social anxiety disorder is accompanied by associated behaviours that are aimed at reducing the anxiety. These include avoiding eye contact, holding
a glass tightly,limiting conversation, or remaining quiet in social conversations. People with social anxiety disorder tend to exaggerate small mistakes
into anxiety-inducing events and may even ruminate on events after they have occurred,with unpleasant thoughts and feelings.They are excessivey
concerned about others' judgements and perceptions of them.

Therefore,social anxiety disorder is a risk factor for substance use, depression,and suicide. It also has a negative impact on the individual's ability to
function in social contexts and,because people with social anxiety disorder do not develop adequate social skills,it can have a negative effect on the
individual's life in the long term.

Many people may be described as shy,but the difference between the two is that, while people who are shy lend to feel uncomfortable in the
presence of others,those with social anxiety disorder experience extreme anxiety in social situations, and they tend to actively avoid such situations.
Exposure to people and social situations usually provokes anxiety in people with social anxiety disorder, and they tend to avoid such situations or they
endure them with intense fear or anxiety.They are usually aware that the fear and anxiety are excessive or unreasonable.

Figure 6.7: Common fears associated with social anxiety disorder

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IXIETY, OBSESSIVE-COMPULSIVE,AND TRAUMA-RELATED DISORDERS

Table 6.4: Symptoms of social anxiety disorder are ilustrated below

Cognitive Physiological Behavioura

Self-consciousness Sweating Avoidance

Social inferiority Blushing Poor eye contact

Negative self-appraisal Tremor Speaking in a soft/inaudible tone

Awareness that feelings and

thoughts are irrational

Epidemiological studies indicate that the prevalence rates for social anxiety disorder range from 3% to 16% in the global population
(Seedat,2013).In general,more females than males present with social anxiety disorder. The median age of onset for this disorder is 13
years.and late onset (after age 30) is uncommon (Schneier & Goldmark, 2015). It may develop as a result of a childhood history of social
inhibition and shyness. Children who experience negative social events such as bullying, or being ridiculed or laughed at while speaking
in front of a group, may remember the impact of that stressful situat ion and be prone to developing social anxiety.Children tend to be
concemed with being able to make friends.and being able to initiate conversations.When these social functions are not adequately
accomplished,the child may develop social anxie ty disorder. In other cases,the disorder may develop slowly,following several social
interactionsand over a long period.

Table 6.5:Diagnostic criteria for socil anxiety disorder from the DSM-5 and ICD-10
A.Marked fear or anxiety about one or more social A disorder in which anxiety is
situations in which the individual is exposed to possible scrutiny by provoked only.or predom inantly.in the
others.Examples include social interactions (e.g. having a situation of possible
conversation, meeting unfamiliar people).
scrutiny by other people.
being observed (e.g.eating or drinking), andperforming in front of
others (e.g.giving a speech). Certain social situations are then
characteristically avoided.or
Note: In children, the anxiety must occur in peer
endured with dread.
settings and not just during interactions with adults.
More pervasive social phobias
8. The individual fears that he or she will act in a way
are usually asociated with fear
or show anxiety symptoms that will be negatively
of criticism and low self-esteem.Secondary
evaluated (i.e. will be humiliating or embarrassing:will manifestations may
lead to rejection or offend others). include blushing, hand tremor.
C. The social situations almost always provoke fear or and nausea. The patient is
anxiety. sometimes convinced that these signs are
Note: In children, the fear or anxiety maybe the primary problem.

expressed by crying,tantrums,freezing,clinging. Symptoms may progress to

shrinking,or failing to speak in social situations. panic attacks.

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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 six 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 physiological effects of a substance (e.g.a drug
of abuse, a medication) or another medical condition.1. The
fear,anxiety,or avoidance is not better explained
by the symptoms of another mental disorder, such as panic
disorder, body dysmorphic disorder,or autism
spectrum disorder.
J. If another medical condition (e.g. Parkinson's disease.
obesity,disfigurement from burns or injury)is present.the
fear,anxiety,or avoidance is clearty unrelated or is excessive.
Source:Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), American
Psychiatric Association (APA). 2013, p. 202, and the /CO-70 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for
Research. World Health Organization (WHO).Geneva.2007.

Generalised anxiety disorder

Generalised anxiety disorder (GAD) is characterised by excessive anxiety and worry (apprehensive expectation) about a
number of events or activities. Typically, people with this disorder describe a sense of persistent worrisome thinking that is
difficult to cont rol and causes distress in their daily lives. To meet the criteria for generalised anxiety disorder,an individual
must experience three (or more) of a possible six symptoms which cause significant distress or impairment in the individual's
social, occupational,or other important area of functioning.

People with generalised anxiety disorder worry excessively about many everyday events.The age of onset is broad,
with many reporting that they have feltanxious and nervous throughout their lives. The symptoms tend to fluctuate
throughout the lifespan,with excessive worry and anxiety being more intense at different periods. In younger
children,generalised anxiety disorder often presents as school-related concems,whereas older individuals tend to be more
concerned with their well-being or that of others.

Females are more susceptible to generalised anxiety disorder than males,as are individuals from more developed
countries in comparison with those from less-developed countries.Anxiety disorders have emerged as the most prevalent
menta I disorders in the general population, with patients often seen in the primary healthcare setting.The incapacity that
 CHAPTER6 ANXIETY,OBSESSIVE-COMPULSIVE,AND TRAUMA-RELATED DISORDERS

results from generalised anxiety disorder is suggested to be as significant as that which results from other chronic medical
illnesses (Hofmann, Dozois, & Smits,2014).

Table 6.6: Diagnostic criteria for generalised anxiety disorder from the DSM-5 and ICD-10

Excessive anxiety or worry (apprehensive or other obsessions in obsessive-compulsive disorder,

expectation),occurring more days than not for separation from attachment figures in separation
A disorder in which the
t six months,about a number of events or anxiety disorder, reminders of traumatic events in
manifestation of anxiety is the
ies (such as work or school performance) posttraumatic stress disorder,gaining weight in
major symptom.
individual finds it difficult to control the worry. anorexia nervosa,physical complaints in somatic
The anxiety is generalised and
anxiety and worry are associated with three (or symptom disorder,perceived appearance flaws in
persistent and not restricted to.
of the following six symptoms (with at least body dysmorphic disorder, having a serious illness in
or even strongly predominating
symptoms having been present for more days illness anxiety disorder, or the content of delusional
in, any particular environmental
ot for the past six months): beliefs in schizophrenia or delusional disorder).
circumstances (i.e. it is free-
ote:Only one item is required in children.
floating').
1) Restlessness or feeling keyed up or on edge.
The dominant symptoms are
2) Being easily fatigued.
variable,but include: complaints
3) Difficulty concentrating or mind going blank.
of persistent nervousness.
4) Imtabiilty.
trembling,muscular tensions,
5) Musc le tension.
sweating,light-headedness.
ep disturbance (difficulty falling or staying
palpitations,dizziness,and
,or restlessness,unsatisfying sleep).
epigastric discomfort.
anxiety, worry,or physical symptoms cause
Fears that the patient or a relative
lly significant distress or impairment in social.
wilI shortly become ill or have an
ational, or other important areas of functioning.
accident are often expressed.
disturbance is not attributable to the
Depressive and obsessional
logical effects of a substance (e.g.a drug of
symptoms,and even some
a medication, or another medical condition
elements of phobic anxiety,are
yperthyroidism).
often present, provided that they
disturbance is not better explained by another
are clearly secondary or less
l disorder (e.g.anxiety or worry about having
severe.
attacks in panic disorder, negative evaluation in

ocial anxiety disorder [social phobia), contamination

 CHAPTER6 ANXIETY,OBSESSIVE-COMPULSIVE,AND TRAUMA-RELATED DISORDERS

Source:Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-
5), American Psychiatric Association (APA). 2013. p. 222, and the ICD-10 Classification of Mental and Behavioural
Disorders: Diagnostic Critena for Researh. World Heath Organizaon (WHO)Geneva, 2007.
 .II Vodacom 11:13 13%

Understanding Psychopathol...

UNDERSTANDING PSYCHOPATHOLOGY

OBSESSIVE-COMPULSIVE AND
RELATED DISORDERS

Obsessive-compulsive disorder (OCD) was included in the chapter on anxiety disorders in earlier versions of the DSM.The disorder was characterised by
the presence of both obsessions and compulsions; however, it was later found that a number of disorders are characterised by only obsessions or
compulsions, rather than both.The new category introduced in the DSM-5 has been named 'Obsessive-compulsive and related disorders'.OCD,together
with a number of new disorders, namely body dysmorphic disorder,hoarding disorder,trichotillomania (hair-pulling disorder),and excoriation (skin-
picking)disorder form this separate chapter in the DSM-5.This new category includes disorders with obsessions,compulsions or both.

Obsessive-compulsive and related disorders, or other symptoms characteristic of these disorders, may be induced by the use of a substance or
medication.The symptoms of this disturbance are triggered as the direct result of using the substnce or medication,or exposure to certain toxins; the
symptoms develop during or soon after exposure to the substance or medication, and the substance/medication must be capable of producing such an
effect. Once the substance/medicationis discontinued, the symptoms usually improve or remit over a certain period (depending on the half-life of the
substance/medication).

Obsessive-compulsive disorder

The hallmarks of obsessive-compulsive disorder (OCD) include obsessions,which are recurrent and persistent thoughts,urges,or images that are
experienced as intrusive and unwanted,and/or compulsions,which are the repetitive behaviours or mental acts that an individual feels driven to perform
in response to an obsession or according to rules that must be applied rigidly.The repetitive thoughts, images, impulses or actions are distressing and
impact negatively on the individual's daily functioning. They are also time-consuming.

The obsessions and compulsions vary. Some obsessions include religious or somatic concerns, as well as concerns about symmetry,hoarding,and
sexually intrusive thought s.Compulsions,aimed at reducing these recurrent and persistent thoughts,include counting,washing,repeating,checking,
ordering,and conducting mental rituals.

This is often a debilitatin condition as it substantially influences an individual's daily functioning.OCD can have an adverse effect on an individual's
relationships,ability to perform their work,and on their overall quality of life.The potential level of impairment to an individual's functioning warrants its
classification as a disorder. OCD has a world-wide prevalence of 1.5% to 3%.The onset of OCD is during childhood for one-third to one-halfof individuals
(Camprodon,Rausch,Greenberg, & Dougherty,2016).OCD is associated with an increased risk of suicidal ideation and suicidal behaviour.
CHAPTER 6 ANXIETY, OBSESSIVE-COMPULSIVE,AND TRAUMA-RELATED DISORDERS

Figure 6.8: People with OCD perform certain acts repeatedly.These acts are aimed at reducing the anxiety associated with
uncontrollable thoughts, impulses or images.

Table 6.7: Diagnostic criteria for obsessive-compulsivedisorder from the DSM-5 and ICD-10

connected in a realistic way with what they are

designed to neutralise or prevent,or are clearly
A Presence ofobsessions,compulsions,or both:Obsessions are excessive.
defined by (1) and(2):

(1) Recurrent and persistent thoughts,urges.or images that are

experienced, at some time during the disturbance,as intrusive and
unwanted,and that in most individuals cause marked anxiety or
distress.

(2) The individual attempts to ignore or suppress such

thoughts,urges, or images. or to neutralise them with some other
thought or action(i.e.by performing a compulsion).

Compulsions are defined by (1)and (2):

(1) Repetitive behaviours (e.g.hand washing.ordering.checking) or

mental acts (e.g.praying.counting,repeating words silently)that the
individual feels driven to perform in response to an obsession to
according to rules that must be applied rigidly.

(2) The behaviours or mental acts are aimed at preventing or

reducing anxiety or distress,or preventing some dreaded event or
situation:however,these behaviours or mental acts are not
The essential feature of this disorder is recurrent obsessional
thoughts or compulsive acts.

Obsessional thoughts are ideas,images,or impulses that enter

the patient's mind again and again in a stereotyped form.

Obsessions are almost invariably distressing and the patient often

tries,unsuccessfully,to resist them.

Obsess ions are recognised as own thoughts, although they are

involuntary and often repugnant.

Compulsive acts or rituals are stereotyped behaviours that are

repeated again and again.

Compu lsions are not inherently enjoyable,nor do they result in

the completion of inherently useful tasks.

Compu Isions function to prevent some objectively unlikely

event,often involvingharm to or caused by the patient, that he or she
fears might otherwise occur.
UNDERSTANDING PSYCHOPATHOLOGY

B. The obsessions or compulsions are time-consuming

(e.g.take more than one hour per day)or cause

clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

C.The obsessive-compulsive symptoms are not

attributable to the physiological effects of a

substance (e.g. a drug of abuse, a medication)or

another mental condition.

D. The disturbance is not better explained by the

symptoms of another mental disorder (e.g.

excessive worries, as in generalised anxiety

The patient usually recognises
disorder, preoccupation with appearance, as in
that this behaviour is pointless
body dysmorphic disorder, difficulty discarding or
or ineffectual,and repeatedly
paring with possessions, as in hoarding disorder;
makes attempts to resist.
hair pulling. as in trichotillomania[hair-pulling
Anxiety is almost invariably
disorder): skin picking as in excoriation (skin-picking
present.
disorderj disorder, stereotypies, as in stereotypic
If compulsive acts are resisted,
movement disorder, ritualised eating behaviour,as
the anxiety gets worse.
in eating disorders:preoccupat ion with substances

or gambling.as in substance-related and addictive

disorders:preoccupation with having an illness,

as in illness anxiety disorder; sexual urges or

fantasies, as in paraphilic disorders; impulses, as in

disruptive, impulse-control, and conduct disorders;

guilty ruminations, as in major depressive disorder,

thought insertionor delusional preoccupations,

as in schizophrenia spectrum and other psychotic

disorders; or repetitive pattems of behaviour, as in

autism spectrum disorder).

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders,fifth edition (DSM-
5), American Psychiatric Association (APA), 2013. p. 237, and the ICD-10 Classification of Mental and Behavioural
Disorders: Diagnostic Cntena for Research. World Health Orgnization (WHO).Geneva 2007.
UNDERSTANDING PSYCHOPATHOLOGY

Body dysmorphic disorder

Body dysmorphic disorder is characterised by a preoccupation with an imagined flaw or 'defect' in one's
appearance. This perceived defect is not observable to others orappears

as slight.Altem atively,where there is a slight flaw in the individual's appearance,the individual's response to that
flaw is markedly excessive. Enrico Morselli introduced the term dysmorphophobia over a century ago. He defined this
disorderas 'the sudden onset and subsequent persistence of an idea of deformity:the individual fears he has
become,or may become deformed,and feels tremendous anxiety of such an awareness' (Fava,1992,p.117).

Body dysmorphic disorder often causes significant distress and impairment in the individual's daily functioning,
involves time-consuming rituals such as gazing in the mirror