UNIT 2

Anxiety, Fear, and Panic

●​ Anxiety is a negative mood state characterized by bodily symptoms of physical tension

and by apprehension about the future.
●​ Anxiety is not pleasant, so why do we seem programmed to experience it almost every
time we do something important?
●​ Surprisingly, anxiety is good for us, at least in moderate amounts. Psychologists have
known for over a century that we perform better when we are a little anxious (Yerkes &
Dodson, 1908).

●​ In short, social, physical, and intellectual performances are driven and enhanced by
anxiety. Without it, few of us would get much done.
●​ Anxiety is a future-oriented mood state, characterized by apprehension because we
cannot predict or control upcoming events.
 ●​ Fear, on the other hand, is an immediate emotional reaction to current danger
characterized by strong escapist action tendencies and, often, a surge in the
sympathetic branch of the autonomic nervous system.
●​ Fear is an intense emotional alarm accompanied by a surge of energy in the autonomic
nervous system that motivates us to flee from danger.

In psychopathology, a panic attack is defined as an abrupt experience of intense fear or acute

discomfort, accompanied by physical symptoms that usually include heart palpitations, chest
pain, shortness of breath, and, possibly, dizziness.

Generalized Anxiety Disorder

●​ The physical symptoms associated with generalized anxiety and GAD differ
somewhat from those associated with panic attacks and panic disorder.
●​ GAD is characterized by muscle tension, mental agitation susceptibility to fatigue
(probably the result of chronic excessive muscle tension), some irritability, and
difficulty sleeping, whereas panic is associated with autonomic arousal,
presumably as a result of a sympathetic nervous system surge.
●​ People with GAD mostly worry about minor, everyday life events, a characteristic
that distinguishes GAD from other anxiety disorders.
●​ Adults typically focus on possible misfortune to their children, family health, job
responsibilities, and more minor things such as household chores or being on
time for appointments.
●​ Children with GAD most often worry about competence in academic, athletic, or
social performance, as well as family issues.

Diagnostic Criteria for Generalized Anxiety Disorder - DSM 5

●​ Excessive anxiety and worry (apprehensive expectation), occurring more days

than not for at least 6 months about a number of events or activities (such as
work or school performance).
●​ The individual finds it difficult to control the worry.
●​ The anxiety and worry are associated with at least three (or more) of the
following six symptoms (with at least some symptoms present for more days than
not for the past 6 months) [Note: Only one item is required in children]:
○​ Restlessness or feeling keyed up or on edge.
○​ Being easily fatigued.
○​ Difficulty concentrating or mind going blank.
○​ Irritability.
○​ Muscle tension.
 ○​ Sleep disturbance (difficulty falling or staying asleep or restless,
unsatisfying sleeр).

●​ The anxiety, worry or physical symptoms cause clinically significant distress or

impairment in social, occupational, or other important areas of functioning.
●​ The disturbance is not due to the direct physiological effects of a substance (e.g.,
a drug of abuse, a medication) or a general medical condition (e.g.,
hyperthyroidism).
●​ The disturbance is not better explained by another mental disorder (e.g., anxiety
or worry about having panic attacks in panic disorder, negative evaluation in
social anxiety disorder).

Statistics

●​ General distribution: Approximately 3.1% of the population meets criteria for GAD
during a given 1-year period and 5.7% at some point during their lifetime. For
adolescents only (ages 13-17), the one-year prevalence is somewhat lower at
1.1%.
●​ Gender: About two-thirds of individuals with GAD are female in both clinical
samples and epidemiological studies (where individuals with GAD are identified
from population surveys), which include people who do not necessarily seek
treatment. But this sex ratio may be specific to developed countries.
●​ Age: Most studies find that GAD is associated with an earlier and more gradual
onset than most other anxiety disorders. The median age of onset based on
interviews is 31. GAD is prevalent among older adults. In the large national
comorbidity study and its replication, GAD was found to be most common in the
group over 45 years of age and least common in the youngest group, ages 15 to
24.

Causes

●​ Individuals with GAD do not respond as strongly to stressors as individuals with

anxiety disorders in which panic is more prominent.
●​ Several studies have found that individuals with GAD show less responsiveness
on most physiological measures, such as heart rate, blood pressure, skin
conductance, and respiration rate than do individuals with other anxiety
disorders.
●​ Therefore, people with GAD have been called autonomic restrictors.
●​ When individuals with GAD are compared with non-anxious "normal"
participants, the one physiological measure that consistently distinguishes the
anxious group is muscle tensionpeople with GAD are chronically tense.
●​ The evidence indicates that individuals with GAD are highly sensitive to threat in
general, particularly to a threat that has personal relevance.
●​ This high sensitivity may have arisen in early stressful experiences where they
learned that the world is dangerous and out of control, and they might not be able
to cope.
●​ Furthermore, this acute awareness of potential threat, particularly if it is personal,
seems to be entirely automatic or unconscious.
●​ Tom Borkovec and his colleagues noticed that although the peripheral auto
nomic arousal of individuals with GAD is restricted, they showed intense
cognitive processing in the frontal lobes as indicated by EEG activity, particularly
in the left hemisphere. This finding would suggest frantic, intense thought
processes or worry with out accompanying images (which would be reflected by
activity in the right hemisphere of the brain rather than the left).
●​ Borkovec suggests that this kind of worry may be what causes these individuals
to be autonomic restrictors.
●​ That is, they are thinking so hard about upcoming problems that they don't have
the attentional capacity left for the all-important process of creating images of the
potential threat, images that would elicit more substantial negative affect and
autonomic activity.
●​ In other words, they avoid images associated with the threat.
●​ It prevents the person from facing the feared or threatening situation, so
adaptation never occurs. This is one major deficit in the way people with GAD
attempt to regulate their intense anxiety.
●​ In summary, some people inherit a tendency to be tense (generalized biological
vulnerability), and they develop a sense early on that important events in their
lives may be uncontrollable and potentially dangerous (generalized psychological
vulnerability).
Treatment
●​ GAD is quite common, and available treatments, both drug and psychological,
are reasonably effective.
●​ Benzodiazepines are most often prescribed for generalized anxiety, and the
evidence indicates that they give some relief, at least in the short term. There is
stronger evidence for the usefulness of antidepressants in the treatment of GAD.
 ●​ Psychological treatments are more effective in the long term.
●​ Individuals with GAD seem to avoid "feelings" of anxiety and the negative affect
associated with threatening images, clinicians have designed treatments to help
patients with GAD process the threatening information on an emotional level,
using images, so that they will feel (rather than avoid feeling) anxious.
●​ These treatments have other components, such as teaching patients how to
relax deeply to combat tension.
●​ CBT for GAD patients involves evoking the worry process during therapy
sessions and confront anxiety-provoking images and thoughts head-on.
●​ Recently, a new psychological treatment for GAD has been developed that
incorporates procedures focusing on acceptance rather than avoidance of
distressing thoughts and feelings in addition to cognitive therapy.
●​ Meditational approaches help teach the patient to be more tolerant of these
feelings.

Panic Disorder

●​ In PD, anxiety and panic are combined in an intricate relationship that can
become as devastating as it was for Mrs. M. Many people who have panic
attacks do not necessarily develop panic disorder.
●​ To meet criteria for panic disorder, a person must experience an unexpected
panic attack and develop substantial anxiety over the possibility of having
another attack or about the implications of the attack or its consequences.
●​ In other words, the person must think that each attack is a sign of impending
death or incapacitation.
●​ A few individuals do not report concern about another attack but still change their
behavior in a way that indicates the distress the attacks cause them.
●​ They may avoid going to certain places or neglect their duties around the house
for fear an attack might occur if they are too active.
●​ Thus, agoraphobic avoidance is simply one way of coping with unexpected panic
attacks.
●​ Other methods of coping with panic attacks include using (and eventually
abusing) drugs and/or alcohol.
●​ Some individuals do not avoid agoraphobic situations but endure them with
"intense dread."
●​ Most patients with panic disorder and agoraphobic avoidance also display
another cluster of avoidant behaviors that we call interoceptive avoidance, or
avoidance of internal physical sensations.
 ●​ These behaviors involve removing oneself from situations or activities that might
produce the physiological arousal that somehow resembles the beginnings of a
panic attack.

Diagnostic Criteria for Panic Disorder DSM-5

●​ 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 (e.g., losing control, having a heart attack, "going crazy"), or
●​ (b) A significant maladaptive change in behavior related to the attacks (e.g.,
behaviors 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.,
hyperthyroid ism, cardiopulmonary disorders).
●​ 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).

Statistics

General Distribution

●​ PD is fairly common. Approximately 2.7% of the population meet criteria for PD

during given 1-year period and 4.7% met them at some point during their lives.
Age

●​ Onset of panic disorder usually occurs in early adult life-from midteens through
about 40 years of age. The median age of onset is between 20 and 24 (Kessler,
Berglund, et al., 2005). Prepubescent children have been known to experience
unexpected panic attacks and occasionally panic disorder, although this is quite
rare.

Gender

●​ Two thirds of the population reporting for panic attacks and agoraphobia are
women.
Causes

●​ It is not possible to understand panic disorder without referring to the triad of

contributing factors: biological, psychological, and social.
●​ We all inherit-some more than others-a vulnerability to stress, which is a
tendency to be generally neurobiologically overreactive to the events of daily life
(generalized biological vulnerability).
●​ But some people are also more likely than others to have an emergency alarm
reaction (unexpected panic attack) when confronted with stress-producing
events.
●​ Particular situations quickly become associated in an individual's mind with
external and internal cues that were present during the panic attack.
●​ Because these cues become associated with a number of different internal and
external stimuli through a learning process, we call them learned alarms.
●​ Approximately 8% to 12% of the population has an occasional unexpected panic
attack, often during a period of intense stress over the previous year. Most of
these people do not develop anxiety. Only approximately 5% go on to develop
anxiety over future panic attacks and thereby meet the criteria for panic disorder,
and these individuals are the ones who are susceptible to developing anxiety
over the possibility of having another panic attack (a generalized psychological
vulnerability).
●​ David Clark emphasizes the cognitive process as most important in panic
disorder. According to him, the specific psychological vulnerability of people with
this disorder to interpret normal physical sensations in a catastrophic way.
●​ In other words, although we all typically experience rapid heartbeat after
exercise, if you have a psychological or cognitive vulnerability, you might interpret
the response as dangerous and feel a surge of anxiety. This anxiety, in turn,
produces more physical sensations because of the action of the sympathetic
nervous system; you perceive these additional sensations as even more
dangerous, and a vicious cycle begins that results in a panic attack.
●​ One hypothesis that panic disorder and agoraphobia evolve from psychodynamic
causes suggested that early object loss and/or separation anxiety might
predispose someone to develop the condition as an adult.
Treatment
●​ SSRIs are currently the indicated drug for panic disorder based on all available
evidence, although sexual dysfunction seems to occur in 75% or more of people
taking these medications.
●​ On the other hand, high-potency benzodiazepines such as alprazolam (Xanax),
commonly used for panic disorder, work quickly but are hard to stop taking
because of psychological and physical dependence and addiction.
●​ Gradual exposure exercises, sometimes combined with anxiety-reducing coping
mechanisms such as relaxation or breathing retraining, have proveр effective in
helping patients overcome agoraphobic behavior whether associated with panic
disorder or not.
●​ Effective psychological treatments have recently been developed that treat panic
disorder directly even in the absence of agora phobia.
●​ Panic control treatment (PCT) concentrates on exposing patients with panic
disorder to the cluster of interoceptive (physical) sensations that remind them of
their panic attacks.
●​ The therapist attempts to create "mini" panic attacks in the office by having the
patients exercise to elevate their heart rates or perhaps by spinning them in a
chair to make them dizzy.
 ●​ Patients also receive cognitive therapy. Basic attitudes and perceptions
concerning the dangerousness of the feared but objectively harmless situations
are identified and modified.
●​ Uncovering these unconscious cognitive processes requires a great deal of
therapeutic skill. Sometimes, in addition to exposure to interoceptive sensations
and cognitive therapy, patients are taught relaxation or breathing retraining to
help them reduce anxiety and excess arousal.

Specific Phobia

How could a phobia impact the following

●​ your everyday life

●​ social settings
●​ work or school

●​ A specific phobia is an irrational fear of a specific object or situation that

markedly interferes with an individual's ability to function.
●​ In earlier versions of the DSM, this category was called "simple" pho bia to
distinguish it from the more complex agoraphobia condition.
●​ Surveys indicate that specific fears of a variety of objects or situations occur in a
majority of the population (Myers et al., 1984).
●​ But the very commonness of fears, even severe fears, often causes people to
trivialize the more serious psychological disorder known as a specific phobia.
●​ Before the publication of DSM-IV in 1994, no meaningful classification of specific
phobias existed.
●​ Now, four major subtypes of specific phobia have been identified:
blood-injection-injury type, situational type (such as planes, elevators, or
enclosed places), natural environment type (for example, heights, storms, and
water), and animal type, A fifth category, "other," includes phobias that do not f it
any of the four major subtypes.

Blood-Injection-Injury Phobia

●​ Many people who suffer from phobias and experience panic attacks in their
feared situations report that they feel like they are going to faint, but they never
do because their heart rate and blood pressure are actually increasing.
●​ This is probably because people with this phobia inherit a strong vasovagal
response to blood, injury, or the possibility of an injection, all of which cause a
drop in blood pressure and a tendency to faint.
 ●​ Therefore, those with blood-injection-injury phobias almost always differ in their
physiological reaction from people with other types of phobia.
●​ The phobia develops over the possibility of having this response. The average
age of onset for this phobia is approximately 9 years.

Situational Phobia

●​ Phobias characterized by fear of public transportation or enclosed places are

called situational phobias.
●​ Claustrophobia, a fear of small enclosed places, is situational, as is a phobia of
flying.
●​ The extent to which PD, agoraphobia, and situational phobias run in families is
also similar, with approximately 30% of first-degree relations having the same or
a similar phobia.
●​ The main difference between situational phobia and panic disorder is that people
with situational phobia never experience panic attacks outside the context of their
phobic object or situation.
●​ Therefore, they can relax when they don't have to confront their phobic situation.
●​ People with panic disorder, in contrast, might experience unexpected, uncued
panic attacks at any time.

Natural Environment Phobia

●​ Sometimes very young people develop fears of situations or events occurring in

nature.
●​ These fears are called natural environment phobias. The major examples are
heights, storms, and water.
●​ These fears also seem to cluster together: if you fear one situation or event, such
as deep water, you are likely to fear another, such as storms.
●​ Many of these situations have some danger associated with them and, therefore,
mild to moderate fear can be adaptive.
●​ These phobias have a peak age of onset of about 7 years. They are not phobias
if they are only passing fears.
●​ They have to be persistent (lasting at least six months) and to interfere
substantially with the person's functioning.

Animal Phobia

●​ Fears of animals and insects are called animal phobias. Again, these fears are
common but become phobic only if severe interference with functioning occurs.
 ●​ There are many places that these people are unable to go, even if they want to
very much, such as to the country to visit someone.
●​ The fear experienced by people with animal phobias is different from an ordinary
mild revulsion.
●​ The age of onset for these phobias, like that of natural environment phobias,
peaks around 7 years.

Diagnostic Criteria for Specific Phobia

●​ Marked fear or anxiety about a specific object or situation (e.g.,flying, heights,

animals, receiving an injection, seeing blood).
●​ The phobic object or situation almost always provokes immediate fear or anxiety.
Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or
clinging.
●​ The phobic object or situation is actively avoided or endured with intense fear or
anxiety.
●​ The fear or anxiety is out of proportion to the actual danger posed by the specific
object or situation, and to the sociocultural context.
●​ The fear, anxiety or avoidance is persistent, typically lasting for 6 months or
more.
●​ The fear, anxiety, or avoidance causes clinically significant distress or impairment
in social, occupational or other important areas of functioning.
●​ 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 (as in agoraphobia);
objects or situations related to obsessions (as in obsessivecompulsive disorder);
reminders of traumatic events (as in posttraumatic stress disorder); separation
from home or attachment figures (as in sepa ration anxiety disorder); or social
situations (as in social anxiety disorder).

Statistics

General distribution

●​ Few people who report specific fears qualify as having a phobia, but for
approximately 12.5% of the population, their fears become severe enough to
earn the label "phobia."
●​ During a given 1-year period the prevalence is 8.7% overall but 15.8% in
adolescents.
 ●​ This is a high percentage, making specific phobia one of the most common
psychological disorders in the United States and around the world (Arrindell et
al., 2003b).

Age

●​ The median age of onset for specific phobia is 7 years of age, the youngest of
any anxiety disorder except separation anxiety disorder.

Gender

●​ As with common fears, the sex ratio for specific phobias is, at 4:1,
overwhelmingly female; this is also consistent around the world.

Causes

●​ Direct experience.
●​ Experiencing a false alarm (panic attack) in a specific situation
●​ Observing someone else experience severe fear (vicarious experience)
●​ Being told about danger
●​ Several things have to occur for a person to develop a phobia.
●​ First, a traumatic conditioning experience often plays a role (even hearing
about a frightening event is sufficient for some individuals).
●​ Second, fear is more likely to develop if we are "prepared"; that is, we
seem to carry an inherited tendency to fear situations that have always
been dangerous to the human race, such as being threatened by wild
animals or trapped in small places.
●​ Third, we also have to be susceptible to developing anxiety about the
possibility that the event will happen again.
Treatment

●​ Although the development of phobias is relatively complex, the treatment is fairly

straightforward.
●​ Specific phobias require structured and consistent exposure-based exercises.
●​ Individuals who attempt to carry out the exercises alone often attempt to do too
much too soon and end up escaping the situation, which may strengthen the
phobia.
●​ In addition, if they fear having another unexpected panic attack in this situation, it
is helpful to direct therapy at panic attacks in the manner described for panic
disorder.
●​ Finally, in cases of blood-injection-injury phobia, where fainting is a real
possibility, graduated exposure-based exercises must be done in specific ways.
●​ Individuals must tense various muscle groups during exposure exercises to keep
their blood pressure sufficiently high to complete the practice.
●​ New developments make it possible to treat many specific phobias, including
blood phobia, in single, session taking anywhere from approximately 2 to 6
hours.
●​ Basically, the therapist spends most of the session with the individual, working
through exposure exercises with the phobia object or situation.
●​ The patient then practices approaching the phobic situation at home, checking in
occasionally with the therapist.
 ●​ It is interesting that in these cases not only does the phobia disappear but in
blood phobia the tendency to experience the vasovagal response at the sight of
blood also lessens considerably.
●​ It is also now clear based on brain-imaging work that these treatments change
brain functioning in an enduring way by modifying neural circuitry in such areas
as the amygdala, insula, and cingulate cortex.
●​ After treatment, responsiveness is diminished in this fear sensitive network, but
increased in prefrontal cortical areas, suggesting that more rational appraisals
were inhibiting emotional appraisals of danger.
●​ Thus, these treatments "rewire" the brain.

Jack, 28 years old, an electronics technician

●​ I reckon I was OK until high school. It was there that I started to get really
anxious if I had to doa presentation to the class. I'd worry about it for days and
the night before I couldn't sleep. When it came to the presentation, l'd be
sweating, blushing, my mouth would go dry...it was like torture. It felt like
everyone in the class was laughing at me. Other social situations were really
difficult too. Going to parties, chatting up girls... I just couldn't do it. I'd stick close
to one or two mates, let them do the talking, and just tag along. I've been pretty
much the same ever since. When I was doing my tech training in the air force, I'd
sit at the back of the class hoping no-one would notice me. If there was any
chance I'd have to talk in front of the class, I'd call in sick or make some lame
excuse. If it was a party, I'd get blind drunk first (and usually end up making a real
mess of myself). I was OK if it was only a couple of mates, but with people I didn't
know or large groups, I was cactus. I knew it was stupid and irrational, but that
just made it worse. Why couldn't I just pull myself together and be confident like
my mates?

Social Anxiety Disorder (Social Phobia)

●​ SAD is more than exaggerated shyness.

●​ Individuals with just performance anxiety, which is a subtype of SAD, usually
have no difficulty with social interaction, but when they must do something
specific in front of people, anxiety takes over and they focus on the possibility
that they will embarrass themselves.
●​ The most common type of performance anxiety, to which most people can relate,
is public speaking. Other situations that commonly provoke performance anxiety
are eating in a restaurant or signing a paper or check in front of a person or
people who are watching.
 ●​ Anxiety-provoking physical reactions include blushing, sweating, trembling, or, for
males, urinating in a public restroom.
●​ What these examples have in common is that the individual is very anxious only
while others are present and maybe watching and, to some extent, evaluating
their behavior.
●​ This is truly social anxiety disorder because the people have no difficulty eating,
writing, or doing things in private. Only when others are watching does the
behavior deteriorate.

Diagnostic Criteria for Social Anxiety Disorder (Social Phobia)

●​ 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
(e.g., having a conversation; meeting unfamiliar people), being observed (e.g.,
eating or drinking), or performing in front of others (e.g., giving a speech). Note:
In children, the anxiety must occur in peer settings and not just in interactions
with adults.
●​ The individual fears that he or she will act in a way, or show anxiety symptoms,
that will be negatively evaluated (i.e., will be humiliating, embarrassing, lead to
rejection, or offend others).
●​ The social situations almost always provoke fear or anxiety. Note: in children, the
fear or anxiety may be expressed by crying, tantrums, freezing, clinging,
shrinking, or failing to speak in social situations.
●​ The social situations are avoided or endured with intense fear or anxiety.
●​ The fear or anxiety is out of proportion to the actual threat posed by the social
situation, and to the sociocultural context.
●​ The fear, anxiety or avoidance is persistent, typically lasting for 6 months or
more.
●​ The fear, anxiety or avoidance causes clinically signifi cant distress or impairment
in social, occupational or other important areas of functioning.
●​ The fear, anxiety or avoidance is not attributable to the effects of a substance
(e.g., a drug of abuse, a medication) or another medical condition.
●​ The fear, anxiety or avoidance is not better explained by the symptoms of
another mental disorder, such as panic disorder (e.g., anxiety about having a
panic attack) or separation anxiety disorder (e.g., fear of being away from home
or a close relative).
●​ If another medical condition (e.g., stuttering, Parkinson's disease, obesity,
disfigurement from burns or injury) is present, the fear, anxiety or avoidance is
clearly unrelated or is excessive.
Statistics

General Distribution

●​ As many as 12.1% of the general population suffer from SAD at some point in
their lives.
●​ In a given 1-year period, the prevalence is 6.8% and 8.2% in adolescents. This
makes SAD second only to specific phobia as the most prevalent anxiety
disorder.
Cultural differences

●​ In the United States, White Americans are typically more likely to be diagnosed
with social anxiety disorder (as well as generalized anxiety disorder and panic
disorder) than African Americans, Hispanic Americans, and Asian Americans
(Asnaani, Richey, Dimaite, Hinton, & Hofmann, 2010).
●​ Cross-national data suggest that Asian cultures show the lowest rates of SAD,
whereas Russian and U.S. samples show the highest rates.
●​ In Japan, the clinical presentation of anxiety disorders is best summarized under
the label shinkeishitsu.
●​ One of the most common subcategories is referred to as taijin kyofusho, which
resembles SAD in some of its forms.
●​ Japanese people with this form of SAD strongly fear looking people in the eye
and are afraid that some aspect of their personal presentation (blushing,
stuttering, body odor, and so on) will appear reprehensible.
●​ Thus, the focus of anxiety in this disorder is on offending or embarrassing others
rather than embarrassing oneself, as in SAD, although these two dis orders
overlap considerably.
●​ Japanese males with this disorder outnumber females by a 3:2 ratio. More
recently, it has been established that this syndrome is found in many cultures
around the world, but predominantly in Asian cultures.
●​ Nevertheless, one manifestation of this set of symptoms called "olfactory
reference syndrome" has even been reported in North America.
●​ The key feature once again is preoccupation with a belief that one is
embarrassing oneself and offending others with a foul body odor.

Causes

●​ We seem to be prepared by evolution to fear certain wild animals and dangerous

situations in the natural environment. Similarly, it seems we are also prepared to
fear angry, critical, or rejecting people.
●​ In a series of studies, Öhman and colleagues noted that we learn more quickly to
fear angry expressions than other facial expressions, and this fear diminishes
more slowly than other types of learning.
●​ Lundh and Öst (1996) demonstrated that people with SAD who saw a number of
pictures of faces were likely to remember critical expressions.
●​ Mogg and colleagues (2004) showed that socially anxious individuals more
quickly recognized angry faces than "normals," whereas "normals" remembered
the accepting expressions.
●​ Other studies show that individuals with SAD react to angry faces with greater
activation of the amygdala and less cortical control or regulation than "normals".
●​ Jerome Kagan and his colleagues have demonstrated that some infants are born
with a temperamental profile or trait of inhibition or shyness that is evident as
early as 4 months of age.
●​ Four-month-old infants with this trait become more agitated and cry more
frequently when presented with toys or other age-appropriate stimuli than infants
without the trait.
●​ First, someone could inherit a generalized biological vulnerability to develop
anxiety, a biological tendency to be socially inhibited, or both.
●​ Second, when under stress, someone might have an unexpected panic attack in
a social situation that would become associated (conditioned) to social cues. The
individual would then become anxious about having additional panic attacks in
the same or similar social situations.
●​ Third, someone might experience a real social trauma resulting in a true alarm.
Anxiety would then develop (be conditioned) in the same or similar social
situations.
●​ But one more factor must fall into place to make it an SAD disorder.
●​ The individual with the vulnerabilities and experiences just described must also
have learned growing up that social evaluation in particular can be dangerous,
creating a specific psychological vulnerability to develop social anxiety.
●​ Evidence indicates that some people with SAD are predisposed to focus their
anxiety on events involving social evaluation.
●​ Some investigators (Bruch & Heimberg, 1994; Rapee & Melville, 1997) suggest
that the parents of patients with social phobia are significantly more socially
fearful and concerned with the opinions of others than are the parents of patients
with panic disorder and that they pass this concern on to their children.
Treatment

●​ Clark and colleagues (2006) evaluated a cognitive therapy program that

emphasized real-life experiences during therapy to disprove automatic
perceptions of danger.
●​ One impressive study compared Clark's cognitive therapу described earlier with
the SSRI drug Prozac, along with instructions to the patients with SAD to attempt
to engage in more social situations (self-exposure). A third group received
placebo plus instructions to attempt to engage in more social activities.
●​ Assessments were conducted before the 16-week treatment, at the midpoint of
treatment, posttreatment, and then after 3 months of booster sessions.
●​ Finally, researchers followed up with patients in the two treatment groups 12
months later.
●​ Several exciting studies suggest that adding the drug D-cycloserine (DCS) to
cognitive behavioral treatments significantly enhances the effects of treatment.

●​ When used with individuals suffering from SAD (or panic disorder), DCS is given
approximately an hour before the extinction or exposure trial, and the individual
does not take the drug on an ongoing basis.

●​ For example, Michael Otto and his colleagues in one of our clinics (Otto et al.,
2010) administered cognitive behavioral intervention to patients with panic
disorder either with or without the drug.

●​ The people who got the drug improved significantly more during treatment than
those who didn't get the drug.

●​ This is particularly noteworthy because the feared cues for people with panic
disorder are physical sensations, and the drug DCS helped extinguish anxiety
triggered by sensations such as increased heart rate or respiration.
 ●​ Stefan Hofmann and colleagues (2006) found a similar result with social anxiety
disorder.

●​ A recent extension of this earlier trial showed that DCS was associated with a
24-33% faster rate of improvement in symptom severity and remission rates
relative to placebo during a full course, 12 week CBT intervention.

Introduction

●​ Obsessive-compulsive and related disorders are a group of overlapping

disorders that generally involve intrusive, unpleasant thoughts and repetitive
behaviors.
●​ The recurring, unwanted, and intrusive thoughts (obsessions) that lead to
repetitive behaviors or mental acts (compulsions) aimed at reducing anxiety.
●​ In 2010, prior to the publishing of DSM-5, a paper entitled 'Should OCD be
classified as an Anxiety disorder in DSM-5?' surveyed authors of OCD
publications internationally.
●​ Approximately 60% of the 187 respondents supported moving OCD out of the
anxiety disorders section, whereas 40% disagreed.
●​ The most frequent reason for supporting a move out of the anxiety disorders
section was that obsessions and compulsions, rather than anxiety are the
fundamental features of the disorder.
●​ The main reasons for disagreeing with such a move were that OCD and other
anxiety disorders respond to similar treatments and tend to co-occur.

DSM-5 Categorisation

In DSM-5, Obsessive-Compulsive Disorder sits under its own category of

Obsessive-Compulsive and Related Disorders and within that the following
subcategories were placed:
●​ Obsessive Compulsive Disorder (OCD).
●​ Body Dysmorphic Disorder (BDD).
●​ Hoarding Disorder.
●​ Trichotillomania.
●​ Excoriation (Skin Picking) Disorder.
●​ Substance/Medication-induced Obsessive-Compulsive and related Disorder.
●​ Obsessive-Compulsive and Related Disorder due to another medical condition.
●​ Other specified Obsessive-Compulsive and Related Disorder.
 ●​ Unspecified Obsessive-Compulsive and Related Disorder.
●​ Some other obsessive-compulsive and related disorders are also characterized
by preoccupations and by repetitive behaviors or mental acts in response to the
preoccupations. Other obsessive-compulsive and related disorders are
characterized primarily by recurrent body-focused repetitive behaviors (e.g., hair
pulling, skin picking) and repeated attempts to decrease or stop the behaviors.
●​ The inclusion of a chapter on obsessive-compulsive and related disorders in
DSM-5 reflects the increasing evidence of these disorders' relatedness to one
another in terms of a range of diagnostic validators as well as the clinical utility of
grouping these disorders in the same chapter.
●​ While the specific content of obsessions and compulsions varies among
individuals, certain symptom dimensions are common in OCD, including those of
cleaning (contamination obsessions and cleaning compulsions); symmetry
(symmetry obsessions and repeating. ordering and counting compulsions);
forbidden or taboo thoughts (e.g., aggressive, sexual and
●​ religious obsessions and related compulsions); and harm (e.g ., fears of harm to
oneself or others and related checking compulsions). The tic-related specifier of
OCD is used when an individual has a current or past history of a tic disorder.

Obsessive-Compulsive Disorder

●​ OCD is the devastating culmination of the anxiety disorders. It is not uncommon

for someone with OCD to experience severe generalized anxiety, recurrent panic
attacks, debilitating avoidance, and major depression, all occurring
simultaneously with obsessive-compulsive symptoms.
●​ Obsessions are intrusive and most likely nonsensical thoughts, images, or urges
that the individual tries to resist or eliminate. Compressions are the thoughts or
actions used to suppress the obsessions and provide relief.
PANDAS
●​ Observations among one small group of children presenting with OCD and tics
suggest that these problems occurred after a bout of strep throat.
●​ This syndrome has been referred to as pediatric autoimmune disorder associated
with streptococcal infection.
●​ Presentation of OCD in these cases differs somewhat from OCD without a history
of "PANDAS" in several ways.
●​ The PANDAS group is more likely to be male; experience dramatic onset of
symptoms often associated with fever or sore throat; have full remissions
 between episodes; show remission of symptoms during antibiotic therapy; have
evidence of past streptococcal infections; and present with noticeable
clumsiness.
●​ Recently, this syndrome has been revised and broadened under the umbrella
term Pediatric Autoimmune Neuropsychiatric Syndrome (PANS).

Diagnostic Criteria for Obsessive Compulsive Disorder

●​ Presence of obsessions, compulsions or both:

○​ Obsessions are 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
inappropriate and that in most individuals cause marked anxiety or
distress
■​ 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 and 2:

■​ 1. Repetitive behaviors (e.g., handwashing, ordering,

checking) or mental acts (e.g., praying, counting, repeating
words silently) 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; however, these behaviors or mental acts either are
not connected in a realistic way with what they are designed
to neutralize or prevent or are clearly excessive.

●​ The obsessions or compulsions are time-consuming (e.g., take more than 1 hour
per day), or cause clinically significant distress or impairment in social,
occupational or other important areas of functioning.
●​ The disturbance is not due to the direct physiological effects of a substance (e.g.,
a drug of abuse, a medication) or another medical condition.
●​ The disturbance is not better explained by the symptoms of another mental
disorder (e.g ., excessive worries, as in generalized anxiety disorder, or
preoccupation with appearance, as in body dysmorphic 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 obsessive- compulsive
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.

Statistics

●​ Estimates of the lifetime prevalence of OCD range from 1.6% to 2.3%, and in a
given 1-year period the prevalence is 1 %.
●​ Not all cases meeting criteria for OCD are severe.
●​ Obsessions and compulsions can be arranged along a continuum, like most
clinical features of anxiety disorders.
●​ Unlike other anxiety and related disorders, OCD has a ratio of female to male
that is nearly 1:1.
●​ Age of onset ranges from childhood through the 30s, with a median age of onset
of 19.
●​ Symmetry obsessions account for most obsessions (26.7%), followed by "for
bidden thoughts or actions" (21 %), cleaning and contamination (15.9%), and
hoarding (15.4%).

Tic Disorder and OCD

●​ It is also common for tic disorder, characterized by involuntary movement

(sudden jerking of limbs, for example), to co-occur in patients with OCD
(particularly children) or in their families.
●​ More complex tics with involuntary vocalizations are referred to as Tourette's
disorder.
●​ Approximately 10% to 40% of children and adolescents with OCD also have had
tic disorder at some point.
●​ The obsessions in tic-related OCD are almost always related to symmetry.

Causes
 ●​ Why would people with OCD focus their anxiety on the occasional intrusive
thought rather than on the possibility of a panic attack or some other external
situation?
●​ One hypothesis is that early experiences taught them that some thoughts are
dangerous and unacceptable because the terrible things they are thinking might
happen and they would be responsible.
●​ When clients with OCD equate thoughts with the specific actions or activity
represented by the thoughts, this is called thought-action fusion .
●​ Thought- action fusion may, in turn, be caused by attitudes of excessive
responsibility and resulting guilt developed during childhood.
●​ Generalized biological and psychological vulnerabilities must be present for this
disorder to develop.
●​ Believing some thoughts are unacceptable and therefore must be suppressed (a
specific psychological vulnerability) may put people at greater risk of OCD.
●​ Several studies showed that the strength of religious belief, but not the type of
belief, was associated with thought-action fusion and severity of OCD.

Treatment
CSTC
In Obsessive-Compulsive Disorder (OCD), the cortico-striato-thalamo-cortical (CSTC)
circuit is implicated in the disorder's neurobiology. Selective Serotonin Reuptake
Inhibitors (SSRIs), a first-line treatment for OCD, are thought to work by modulating the
activity of this circuit, specifically by increasing serotonin levels in the brain. This
modulation is believed to help normalize the abnormal activity within the CSTC circuit
that is often observed in individuals with OCD.
●​ The most effective drugs seem to be those that specifically inhibit the reuptake of
serotonin, such as clomipramine or the SSRIs, which benefit up to 60% of
patients with OCD, with no particular advantage to one drug over another.
●​ The most effective approach is called exposure and ritual prevention (ERP), a
process whereby the rituals are actively prevented and the patient is
systematically and gradually exposed to the feared thoughts or situations.
●​ ERP, with or without the drug, produced superior results to the drug alone, with
86% responding to ERP alone versus 48% to the drug alone.
●​ Combining the treatments did not produce any additional advantage.
●​ Also, relapse rates were high from the medication-only group when the drug was
withdrawn.
●​ Psychosurgery is one of the more radical treatments for OCD. "Psychosurgery" is
a misnomer that refers to neurosurgery for a psychological disorder.
●​ The advantage of deep brain stimulation over more traditional surgery is that it is
reversible.
 ●​ Considering that these patients seemed to have no hope from other treatments,
surgery deserves consideration as a last resort.

Trichotillomania

●​ The urge to pull out one's own hair from anywhere on the body, including the
scalp, eyebrows, and arms, is referred to as trichotillomania.
●​ Compulsive hair pulling is more common than once believed and is observed in
between 1% and 5% of college students, with females reporting the problem
more than males.
●​ Some genetic influence.
●​ Excoriation (skin picking disorder) is characterized, as the label implies, by
repetitive and compulsive picking of the skin, leading to tissue damage.
●​ Psychological treatments, particularly an approach called "habit reversal
training," has the most evidence for success with these two disorders.
●​ In this treatment, patients are carefully taught to be more aware of their repetitive
behavior, particularly as it is just about to begin, and to then substitute a different
behavior, such as chewing gum, applying a soothing lotion to the skin, or some
other reasonably pleasurable but harmless behavior.

Treatment

●​ The most effective drugs seem to be those that specifically inhibit the reuptake of
serotonin, such as clomipramine or the SSRIs, which benefit up to 60% of
patients with OCD, with no particular advantage to one drug over another.
●​ The most effective approach is called exposure and ritual prevention (ERP), a
process whereby the rituals are actively prevented and the patient is
systematically and gradually exposed to the feared thoughts or situations.
●​ ERP, with or without the drug, produced superior results to the drug alone, with
86% responding to ERP alone versus 48% to the drug alone.
●​ Combining the treatments did not produce any additional advantage.
●​ Also, relapse rates were high from the medication-only group when the drug was
withdrawn.
●​ Psychosurgery is one of the more radical treatments for OCD. "Psychosurgery" is
a misnomer that refers to neurosurgery for a psychological disorder.
●​ The advantage of deep brain stimulation over more traditional surgery is that it is
reversible.
●​ Considering that these patients seemed to have no hope from other treatments,
surgery deserves consideration as a last resort.
Body Dysmorphic Disorder

●​ BDD is a preoccupation with some imagined defect in appearance by someone

who actually looks reasonably normal. The disorder has been referred to as
"imagined ugliness".
●​ Dysmorphophobia (literally, fear of ugliness), was thought to represent a
psychotic delusional state because the affected individuals were unable to
realize, even for a fleeting moment, that their ideas were irrational.
●​ In mental health clinics, the disorder is also uncommon because most people
with BDD seek other types of health professionals, such as plastic surgeons and
dermatologists.
●​ BDD is seen equally in men and women.
●​ Men tend to focus on body build, genitals, and thinning hair and tend to have
more severe BDD.
●​ Women focus on more varied body areas and are more likely to also have an
eating disorder.

●​ Individuals with BDD react to what they think is a horrible or grotesque feature.
●​ Thus, the psychopathology lies in their reacting to a "deformity" that others
cannot perceive.
●​ Social and cultural determinants of beauty and body image largely define what is
"deformed."
 ●​ No etiological evidences of BDD are known, except that it has a comorbidity with
OCD.
●​ There are two, and only two, treatments for BDD with any evidence of
effectiveness, and these treatments are the same found effective in OCD.
●​ First, drugs that block the re-uptake of serotonin, such as clomipramine, second,
exposure and response prevention, the type of cognitive-behavioral therapy
effective with OCD, has also been successful with BDD.

Post traumatic stress disorder

PTSD

Cause

●​ PTSD is the one disorder for which we know the cause at least in terms of the
precipitating event: someone personally experiences a trauma and develops a
disorder.
●​ Whether or not a person develops PTSD, however, is a surprisingly complex
issue involving biological, psychological, and social factors.
●​ The greater the vulnerability, the more likely to develop PTSD.
●​ A family history of anxiety suggests a generalized biological vulnerability for
PTSD.
●​ True and colleagues (1993) reported that, given the same amount of combat
exposure and one twin with PTSD, a monozygotic (identical) twin was more likely
to develop PTSD than a dizygotic (fraternal) twin.
●​ Breslau, Davis, and Andreski (1995; Breslau, 2012) demonstrated among a
random sample of 1,200 individuals that characteristics such as a tendency to be
anxious, as well as factors such as minimal education, predict exposure to
traumatic events in the first place and therefore an increased risk for PTSD.
●​ Similarly, positive coping strategies involving active problem solving seemed to
be protective, where as becoming angry and placing blame on others were
associated with higher levels of PTSD.
●​ A number of studies show that support from loved ones reduces cortisol
secretion and hypothalamic-pituitary-adrenocortical (HPA) axis activity in children
during stress.
●​ Chronic arousal associated with HPA axis and some other symptoms of PTSD
may be directly related to changes in brain function and structure.
●​ For example, evidence of damage to the hippocampus has appeared in groups
of patients with war-related PTSD adult survivors of childhood sexual abuse and
firefighters exposed to extreme trauma.
 ●​ The hippocampus is a part of the brain that plays an important role in regulating
the HPA axis and in learning and memory.
●​ Thus, if there is damage to the hippocampus, we might expect persistent and
chronic arousal as well as some disruptions in learning and memory.
●​ These memory deficits are evident in veterans of the Gulf War and Holocaust
survivors with PTSD, as compared with Holocaust survivors without PTSD or
healthy Jewish adults.

Treatment

●​ From the psychological point of view, most clinicians agree that victims of PTSD
should face the original trauma, process the intense emotions, and develop
effective coping procedures in order to overcome the debilitating effects of the
disorder.
●​ In psychoanalytic therapy, reliving emotional trauma to relieve emotional suffering
is called catharsis.
●​ Therefore, imaginal exposure, in which the content of the trauma and the
emotions associated with it are worked through systematically, has been used for
decades under a variety of names.
●​ Cognitive therapy to correct negative assumptions about the trauma-such as
blaming oneself in some way, feeling guilty, or both-is often part of treatment.
●​ Personality and other characteristics, some of them at least partially heritable,
may predispose people to the experience of trauma by making it likely that they
will be in (risky) situations where trauma is likely to occur.
●​ Also, there seems to be a generalized psychological vulnerability described in the
context of other disorders based on early experiences with unpredictable or
uncontroltable events.
●​ Foy and colleagues (1987) discovered that at high levels of trauma, these
vulnerabilities did not matter as much, because the majority (67%) of prisoners of
war that they studied developed PTSD.
●​ At low levels of stress or trauma, however, vulnerabilities matter a great deal in
determining whether the disorder will develop.
●​ Psychological factors either protect against or increase the risk of developing
PTSD.
●​ Finally, social factors play a major role in the development of PTSD. The results
from a number of studies are consistent in showing that, if you have a strong and
supportive group of people around you, it is much less likely you will develop
PTSD after a trauma.