1. Chapter 4
Anxiety, Trauma- and Stressor- Related, and Obsessive-Compulsive and Related Disorders

2. Outline Introduction to Anxiety Anxiety Disorders
Generalized anxiety disorder
Panic Disorder and agoraphobia
Specific phobias
Social anxiety disorder
Trauma- and stressor-related disorders
PTSD
Obsessive-Compulsive and Related Disorders

3. Fear Fear – present-oriented mood state
Immediate fight or flight response to danger or threat
Involves abrupt activation of the sympathetic nervous system
Strong avoidance/escapist tendencies
Marked negative affect

4. Anxiety Anxiety – future-oriented mood state
Apprehension about future danger or misfortune
Physical symptoms of tension
Characterized by marked negative affect
May lead to avoidance of situations likely to provoke fear
Anxiety and fear are normal emotional states

5. From Normal to Disordered Fear and Anxiety
Characteristics of anxiety disorders
Pervasive and persistent symptoms of anxiety and fear
Involve excessive avoidance and escape
Cause clinically significant distress and impairment

6. The Phenomenology of Panic Attacks
A panic attack is an abrupt experience of intense fear
Physical symptoms: heart palpitations, chest pain, dizziness, sweating, chills or heat sensations, etc.
Cognitive symptoms: Fear of losing control, dying, or going crazy
Two types
Expected
Unexpected

7. DSM Criteria: Panic Attack

8. Anxiety, Fear and Panic
FIGURE 4.1  The relationships among anxiety, fear, and panic attacks

9. Biological Contributions to Anxiety and Panic
Genetic vulnerability
More likely to be anxious if there is a family history of anxiety
Anxiety and brain circuits
Depleted levels of GABA are associated with more anxiety
Deficits in norepinephrine and serotonin are also associated with greater anxiety
GABA is an inhibitory neurotransmitter, i.e., it makes brain cells LESS likely to fire
Norepinephrine (also called noradrenaline) and serotonin are also neurotransmitters

10. Biological Contributions to Anxiety and Panic
Behavioral inhibition system (BIS)
Septal-Hippocampal system in the Limbic System to the frontal cortex – responds to threat signals by inhibiting activity and causing anxiety
Fight/flight system (FFS)
“Sympathetic response”
Fear (can eventually lead to anxiety)

11. Psychological Contributions to Anxiety and Fear
Early childhood experiences
Uncontrollability and unpredictability
Observational learning/modeling
Social contributions
Stressful life events trigger vulnerabilities
Behavioral and cognitive views
Invokes conditioning and cognitive explanations
Anxiety and fear are learned responses
Catastrophic thinking and appraisals play a role

13. An Integrated Model Integrative view – triple vulnerability model
Generalized biological vulnerability
Generalized psychological vulnerability
Specific psychological vulnerability

14. Triple Vulnerability Model
FIGURE 4.2  The three vulnerabilities that contribute to the development of anxiety disorders. If individuals possess all three, the odds are greatly increased that they will develop an anxiety disorder after experiencing a stressful situation. (From Barlow, D. H., Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.). New York: Guildford Press.)

15. Comorbidity Comorbidity – having more than one diagnosis at once
Common across the anxiety disorders
Major depression is the most common secondary diagnosis
About half of patients have two or more secondary diagnoses
Implications
Common factors create and maintain disorders
A relation between anxiety and depression

17. Anxiety Disorders Generalized anxiety disorder (GAD)
Panic disorder (PD)
Agoraphobia
Social anxiety disorder (SAD)
Specific phobias
Separation anxiety disorder
Selective mutism
- Selective mutism and separation anxiety disorder are new to the anxiety disorders in DSM-5.

18. Generalized Anxiety Disorder (GAD)
Overview and defining features
Excessive uncontrollable anxious apprehension and worry about multiple areas of life (e.g., work, relationships, health); chronic in nature
Persists for six months or more
Accompanied by associated symptoms (e.g., muscle tension, restlessness, fatigue, irritability, concentration difficulties, sleep disturbance)

19. DSM-5 Criteria for GAD

20. GAD: Statistics Affects about 3.1% of the general population
Females outnumber males approximately 2:1
Onset is often insidious, beginning in early adulthood
Very prevalent among the elderly
Tends to run in families

21. GAD: Associated Features
Genetics – not GAD, but the tendency to become anxious
Chronically tense – high muscle tension
Highly sensitive to personal threat
“Automatic restrictors”
Individuals with GAD show less responsiveness on most physiological measures (e.g., heart rate, blood pressure) than individuals with other anxiety disorders
Intense “cognitive processing” in frontal lobes
Results in constant worrying = fail to process emotional component of thoughts and images (i.e., mental avoidance)

22. GAD: Treatment
Psychological treatments are typically more effective than medications in the long-term
Cognitive-behavioral therapy (CBT) has the best outcomes
Can include elements of “acceptance” of distressing thoughts and feelings (rather and avoidance) and meditation
Medications
Benzodiazepines – often prescribed
Can provide immediate relief, but can impair cognitive and motor functioning and can produce both psychological and physical dependence
Antidepressants – SSRIs; may be treatment of choice

23. Integrative Model of GAD
FIGURE 4.3  An integrative model of GAD.

25. Panic Disorder Overview and defining features
Experience of unexpected panic attack (i.e., a false alarm)
Develop anxiety, worry, or fear about another attack
Many develop Agoraphobia (discussed next)

26. DSM-5 Criteria for Panic Disorder

27. PANIC! PANIC! PANIC! PANIC!
Recall: Panic Attack Symptoms
sweating
racing heart
chest pain
shortness of breath
dizziness
nausea
hot flashes/chills
trembling
terror
desire to escape
PANIC! PANIC! PANIC! PANIC!

28. Panic Disorder and Agoraphobia
Fear of being in places in which it would be difficult to escape or get help in the event of unpleasant physical symptoms (e.g., panic attack, dizziness, vomiting, incontinence)
Typically results in being “housebound” or only being able to leave your house within a certain radius
Panic and agoraphobia often occur together
Coupled together in previous editions of the DSM – i.e., “Panic disorder with agoraphobia,” “Agoraphobia without a history of panic disorder”
May occur independently

29. DSM-5 Criteria for Agoraphobia

30. Agoraphobia

31. Panic Disorder Statistics Cultural influences
Affects about 2.7% of the general population
Onset is often acute, mean onset between 20 and 24 years of age
66% of individuals with agoraphobia are female
Cultural influences
Panic attacks interpreted differently across cultures

32. Risk Factors for Developing Panic Disorder
Vulnerability to stress = strong “alarm” system
Generally higher emotional reactivity to stressors
Higher likelihood of having physical alarm reaction in response to stress
Tendency to believe that bodily sensations are dangerous or associated with catastrophic outcomes

33. Panic Disorder: Associated Features
Nocturnal panic attacks – 60% panic during deep non-REM sleep
Interoceptive/exteroceptive avoidance
Avoid situations/activities that may elicit certain physiological arousal
Isolated sleep paralysis – appears to be culturally determined
Occurs during the transitional state between sleep and waking
The individual is unable to move and experiences a surge of terror similar to a panic attack; rare – vivid hallucinations

34. Isolated Sleep Paralysis
FIGURE 4.4  Isolated sleep paralysis in African Americans (AA) and Caucasian Americans with panic disorder (PD), other anxiety disorder (AD) but not panic disorder, and community volunteers with no disorder. (Adapted from Paradis, C. M., Friedman, S., & Hatch, M., Isolated sleep paralysis in African-Americans with panic disorder. Cultural Diversity & Mental Health, 3, 69–76.)

35. Panic Disorder: Treatment
CBT is highly effective (best outcomes)
Panic Control Treatment (PCT)
Specific CBT approach where panic sensations are purposefully triggered to build tolerance
Medications
SSRIs (e.g., Prozac and Paxil) or benzodiazepines (e.g., Ativan)
SSRIs are preferred
Relapse rates are high following medication discontinuation, especially benzodiazepines

36. Panic Disorder: Treatment
Psychological and combined treatments
No evidence that combined treatment produces better outcome than CBT alone
In fact, best long-term outcome is with CBT alone

37. CBT & Medication vs. CBT Alone
FIGURE 4.6  This figure shows relapse rates in patients after receiving various combinations of CBT, medication and placebo (PBO).
Note: The figure is a bit confusing to grasp. Higher bars indicate worse outcome (i.e., higher rate of relapse). The main point is that having imipramine as part of the treatment led to higher relapse rates after it was discontinued – even if they got CBT along with it. See p. 132 of the textbook for a more detailed explanation.

38. Integrative Model of PD and Agoraphobia
FIGURE 4.5  A model of the causes of panic disorder with or without agoraphobia. (Reprinted, with permission, from White, K. S., & Barlow, D. H., Panic disorder and agoraphobia. In D. H. Barlow, Anxiety and its disorders: The nature and treatment of anxiety and panic, 2nd ed. New York: Guilford Press, © 2002 by Guilford Press.)

40. Specific Phobias Overview and defining features
Extreme irrational fear of a specific object or situation
Persons will go to great lengths to avoid phobic objects
Most recognize that the fear and avoidance are unreasonable
Markedly interferes with one’s ability to function

41. DSM-5 Criteria: Specific Phobias

42. Specific Phobias Statistics Cultural influences
Females are again over-represented (varies by phobia)
Affects about 12.5% of the general population
One of the most common psychological disorders in the U.S. and around the world
Phobias tend to run a chronic course
Only the most severe cases seek treatment
Mildly affected people tend to work around their phobias
Cultural influences
Certain objects feared more in different cultures

43. Specific Phobias: Subtypes
Animals (e.g., bees, dogs, snakes)
Natural environment (e.g., storms, heights, water)
Situational (e.g., bridges, elevators, flying, driving, enclosed places)
Blood-injury-injection (e.g., blood draws, getting injections, seeing blood from a minor cut, watching others get blood drawn or injections)
Sometimes associated with unusual vasovagal response (e.g., fainting)
Other – e.g., fear of chocking, vomiting, contracting an illness

45. Specific Phobia

46. Specific Phobias: Causes and Treatment
Causes of phobias
Traumatic conditioning
Direct experience – real danger or pain results in a true alarm response
Vicarious – observational learning
Information transmission – receive information/warned
*Thoughts/worry that the event will happen again
Prepared tendency
Biological and evolutionary vulnerability
CBT is highly effective – exposure is critical

47. Integrative Models of Specific Phobias
FIGURE 4.7  A model of the various ways a specific phobia may develop. (From Barlow, D. H., Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.). New York: Guildford Press.)

49. Social Phobia Overview and defining features
Extreme fear (often irrational) in social or performance situations
Markedly interferes with one’s ability to function
Often avoid social situations or endure them with great distress
Performance-only subtype – Anxiety only occurs in performance situations (e.g., public speaking) without anxiety in everyday interactions

50. DSM-5 Criteria for Social Anxiety Disorder

51. Social Phobia: Statistics
Affects about 12.1% of the general population, 6.8% in 1-year period
Prevalence is slightly greater in females than males
Second only to specific phobia in the anxiety disorders
Onset is usually during adolescence
Peak age of onset at about 13 years

52. Social Phobia: Causes and Treatment
Biological and evolutionary vulnerability
Adaptive to fear rejection
Similar learning pathways as specific phobias
CBT and group CBT are both highly effective
Medications
Often treated with SSRIs
Relapse rates are high following discontinuation

53. Integrative Model of Social Phobia
FIGURE 4.8  A model of the various ways a social phobia may develop. (From Barlow, D. H., Anxiety and its disorders: The nature and treatment of anxiety and panic. (2nd ed.). New York: Guilford Press.)

55. Separation Anxiety Disorder (SAD)
Characterized by unrealistic and persistent worry that something will happen to self or loved ones when apart (e.g., kidnapping, accident) as well as anxiety about leaving loved ones
4.1% of children meet criteria, 6.6% for adults
Used to be diagnosed in children only, but now may be diagnosed in adults

56. Selective Mutism
Rare childhood disorder characterized by a lack of speech
Must occur for more than one month and cannot be limited to the first month of school
High comorbidity with SAD
Treatment
CBT most efficacious, similar to treatment for SAD
Used to be classified among childhood mental disorders. Although it does occur in children, it is now considered among anxiety disorders because of the high comorbidity with social anxiety, the role played by anxiety, and its response to treatments that target anxiety

58. Trauma- and Stressor-Related Disorders
New classification in DSM-5
Grouped together because of shared origin: stressful life events
Include PTSD and acute stress disorder, adjustment disorders, and attachment disorders

59. Posttraumatic Stress Disorder (PTSD)
Overview and defining features
Main etiologic characteristics – trauma exposure and response
Reexperiencing (e.g., memories, nightmares, flashbacks)
Avoidance
Emotional numbing and interpersonal problems
Markedly interferes with one's ability to function
PTSD diagnosis – only after one month post-trauma
Acute Stress Disorder – symptoms begin within four weeks of event and last for less than one month

60. DSM-5 Criteria for PTSD

61. Posttraumatic Stress Disorder (PTSD): Statistics
Many individuals who experience trauma do not go on to develop PTSD
i.e., lower than expected prevalence rates in trauma victims
Approximately 7% of people experience PTSD at some point in their lives
Combat and sexual assault are the most common traumas

62. PTSD: Subtypes Acute – may be diagnosed one-three months post trauma
Chronic – diagnosed after three months post trauma
Delayed onset – onset six months or more post trauma
Acute stress disorder – PTSD immediately post-trauma (up to one month)

63. PTSD: Causes
Intensity of the trauma and one's reaction to it (i.e., true alarm)
Learned alarms – direct conditioning and observational learning
Biological vulnerability
Uncontrollability and unpredictability
Quality of social support post-trauma

64. PTSD Diagnosis rates based on type of exposure to trauma
FIGURE 4.9  Prevalence of lifetime and current PTSD associated with assault characteristics. (Reprinted, with permission, from Resnick, H. S., Kilpatrick, D. G., Dansky, B. S., Sanders, B. E., & Best, C. L., Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. Journal of Consulting and Clinical Psychology, 61, 984–991, © 1993 American Psychological Association.)

65. PTSD: Treatment CBT is highly effective Medications
Common CBT elements:
Graduated or massed (e.g., flooding) imaginal exposure
Develop narrative of traumatic event to process understanding (e.g., Trauma-Focused CBT)
Challenge maladaptive beliefs about the world (e.g., interpersonal relationships are unsafe)
Medications
Generally use medications effective against anxiety and panic
SSRIs most common

66. Integrative Model of PTSD
FIGURE 4.10  A model of the causes of PTSD. (Reprinted, with permission, from Barlow, D. H., Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.). New York: Guilford Press, © 2002 Guilford Press.)

68. Adjustment Disorders Anxious or depressive reactions to life stress
Milder than PTSD (or MDD)
Occur in reaction to life stressors like moving, new job, divorce, etc.
Clinically significant distress or impairment in work/school performance, interpersonal relationships, or other areas of living

69. Attachment Disorders
Disturbed and developmentally inappropriate behaviors in children, emerging before five years of age
Child is unable or unwilling to form normal attachment relationships with caregiving adults
Occurs as a result of neglectful or abusive child-rearing practices
The result is a failure to meet the child’s basic emotional needs for affection, comfort, or even providing for basic daily needs

70. Attachment Disorders Reactive Attachment Disorder
The child will seldom seek out a caregiver for protection, support, and nurturance and will seldom respond to offers from caregivers to provide this kind of care
Often evidence lack of responsiveness, limited positive affect, and additional heightened emotionality, such as fearfulness and intense sadeness

71. Attachment Disorders Disinhibited Social Engagement Disorder
The child shows no inhibitions whatsoever to approaching adults
Such a child might engage in inappropriately intimate behavior by showing a willingness to immediately accompany an unfamiliar adult figure somewhere without first checking back with a caregiver

73. Obsessive-Compulsive and Related Disorders
New Classification in DSM-5
Grouped together because of shared features including obsessive thoughts and/or compulsive behaviors
Includes OCD, hoarding disorder, body dysmorphic disorder, trichotillomania, and excoriation

74. Obsessive-Compulsive Disorder (OCD)
Overview and defining features
Obsessions – recurrent, intrusive and distressing nonsensical thoughts, images, or urges
Often neutralized by compulsive behaviors
Compulsions – repetitive, ritualistic, time-consuming behaviors (or “mental acts”) to neutralize anxious thoughts
Only reduces anxiety for a short period
Vicious cycle of obsessions and compulsions

75. OCD

77. DSM-5 Criteria for OCD

78. OCD: Statistics Affects about 2% of the general population
Approximately equal gender distribution
Similar incidence and presentation across cultures
Onset is typically in early adolescence or young adulthood
OCD tends to be chronic

79. OCD: Causes Parallels the other anxiety disorders
Early life experiences
Learning that some thoughts are dangerous/unacceptable
Thought-action fusion – the thought is similar to the action; thinking something will make it more likely to happen

80. OCD: Treatment Cognitive-behavioral therapy is most effective
Involves exposure to anxious cues and prevention of ritualized responses (i.e., exposure and ritual prevention [ERP])
e.g., touching door handles and not washing hands afterward
e.g., saying blasphemous phrase and not engaging in ritualized prayer afterward
Combining CBT with medication – no better than CBT alone
ERP more effective than medications

81. OCD: Treatment Medications
Clomipramine and other SSRIs – benefit up to 60% of patients
Relapse is common with medication discontinuation
Psychosurgery (cingulotomy – lesion of the cingulate bundle) is used in extreme cases

82. Integrative Model of OCD
FIGURE 4.10  A model of the causes of obsessive-compulsive disorder. (Reprinted, with permission, from Steketee, G., & Barlow, D. H., Obsessive-compulsive disorder. In Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed., p. 536). New York: Guilford Press, © 2002 Guilford Press.)

84. Hoarding Disorder Previously considered a type of OCD
Characterized by excessively collecting or keeping items regardless of their value, difficulty discarding items, and living with excessive clutter under conditions best characterized as gross disorganization
Great anxiety and distress to throw anything away (because it might be something important)
May have potential use or sentimental value
Can become extension of own identity
Causes clinically significant distress or impairment
e.g., house too cluttered to live in [extreme cases – condemned by public health], involvement with social services for neglect of children, arguments (and resentment) with family members

85. Hoarding Disorder Prevalence rates of 2-5%
Affects males and females equally
Often begins during teenage years and escalates
Gets worse over time
Often experience great pleasure (sometimes euphoria) from shopping/collecting various items
Often in response to depressive feelings – “retail therapy”

86. Hoarding Disorder
Most individuals do not consider that they have a problem until family members or authorities insist that they seek help
Hoarding residence fires account for 24% of all fire related fatalities
Treatments teach people to assign different values to objects and to reduce anxiety about throwing away items that are somewhat less valued
Appears to be effective, but more research needed on the long-term effects of treatment

88. Body Dysmorphic Disorder (BDD)
A preoccupation with some imagined defect in appearance
Actual defect, if present, appears slight to others
Common locations for perceived defects include:
Skin (73%), hair (56%), nose (37%), eyes (20%), legs (18%), chin (11%), breasts/chest/nipples (21%), stomach (22%), lips (12%), body build (16%), and face size/shape (12%)
Often leads to compulsive behaviors (e.g., repeated mirror checking)

89. DSM-5 Criteria for BDD

90. BDD: Statistics More common than previously thought
1-2% of general population
4% to 28% of college students meet the criteria for this disorder at some point
Seen equally in males and females
Many remain single, and many seek out plastic surgeons
Usually runs a lifelong chronic course
Suicidal ideation and behavior are common

91. Percentage of People with BDD Who Experienced a Problem due to BDD20 40 60 80
100 99
Interference with social functioning 95
Periods of avoidance of nearly all social interactions 90
Interference with work or academic functioning 80
Periods of complete avoidance of work, school, etc. 29
Housebound for at least one week 94
Felt depressed 26
Psychiatrically hospitalized at least once 63
Thought about suicide 14
Attempted suicide

92. BDD: Causes and Treatment
Little is known for causal factors – disorder tends to run in families (similar to OCD)
Parallels treatments for OCD
CBT: Exposure to anxiety (e.g., not wearing makeup) & preventing compulsions (e.g., no mirror available)
Medications (i.e., SSRIs) that work for OCD provide some relief
Plastic surgery
Study of BDD patients: 76.4% had sought this type of treatment and 66% were receiving it
8% to 25% of all patients who request plastic surgery may have BDD
May worsen condition; unlikely to help

94. Trichotillomania
The urge to pull out one’s own hair from anywhere on the body
Leads to noticeable hair loss on scalp, eyebrows, arms, pubic region, etc.
Can also lead to significant distress and significant social impairments/consequences
May go to great lengths to conceal their behavior
Observed in 1-5% of college students (more females than males)
May be a genetic influence (much unknown)

95. Excoriation
Repetitive and compulsive picking of the skin, leading to tissue damage
There can be significant embarrassment, distress, and impairment in terms of social and work functioning
Rates of 1-5% in the general population where there is noticeable damage to the skin, sometimes requiring medical attention
Predominately affects females

96. Trichotillomania & Excoriation: Treatment
“Habit reversal training” (variation of CBT) has the most evidence for success for both disorders
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
SSRIs may be effective for Trichotillomania, but mixed results for Excoriation

98. Summary of the Anxiety Disorders
Most common forms of psychopathology
Anxiety and related disorders occur when natural and adaptive processes (anxiety, fear, and panic) become disproportionate to the environment
From a normal to a disordered experience of anxiety and fear:
Triple vulnerabilities – bio-psycho-social
Fear and anxiety – non-dangerous bodily or environmental cues
Symptoms and avoidance – significant distress and impairment

99. Summary of the Anxiety Disorders
Overall, the most effective treatment for anxiety disorders is CBT
Similar treatments for different anxiety disorders
Suggests that anxiety-related disorders share common processes
Medications may be helpful for treating anxiety disorders in the short-term, but CBT shows the best long-term outcomes