Chapter 4 (revised)

Chapter 11: Strategic Leadership

Chapter 4Chapter 4

ANXIETY, OBSESSIVE-COMPULSIVE AND TRAUMA RELATED DISORDERS


Chapter outline

• Introduction• Fear, anxiety and stress• History of anxiety and panic disorders• Clinical picture • Section 1: Anxiety Disorders• Section 2: Obsessive-Compulsive and related

disorders• Section 3: Trauma and stressor related disorders• Cross cultural and African perspectives


Introduction

• Most common category of mental disorders;• Prescription drugs and general health care for

those with anxiety problems is costly.• 74% have co-morbid mental disorder.• Sex bias: Women at greater risk.• Anxiety results from interplay of phenomena:

• cognitive• perceptual• psychological• physical


Introduction, cont.Understanding the difference between problematic

anxiety and worry that is still ‘within normal limits’ is important in psychology.


Introduction, cont.

• Anxiety that is not excessive is a normal state that aids functioning.

• Anxiety is dysfunctional when it causes significant distress and impairment.

• Worry, or anxious apprehension, very common in people with anxiety disorders.

• Albert Ellis described ‘meta-worry’, or worry about worry, which could complicate treatment.


Introduction, cont.

Fear• Present-oriented mood state.• Marked negative affect.• Immediate fight or flight response to danger or

threat.• Strong avoidance/escapist tendencies.• Abrupt activation of the sympathetic nervous

system.


Introduction, cont.

Anxiety• Future-oriented mood state.• Marked negative affect.• Somatic symptoms of tension.• Apprehension about future danger or

misfortune.

• Anxiety and fear are normal emotional states in response to threat.

• Most people have experienced some physical symptoms of anxiety.


Introduction, cont.

Anxious and depressed mood frequently share a similar presentation.


Introduction, cont.


Introduction, cont.

Stress• Medical field focuses on negative stressful life

demands.• Selye distinguished ‘distress’ and ‘eustress’.• General Adaptation Syndrome (GAS):

• Phase 1: Fear and ‘alarm response’ • Phase 2: ‘Resistance’• Phase 3: ‘Exhaustion’ (chronic stress and

damage)• Ongoing or unmanageable stress

• negative effect on immune system • causation or maintenance of physical disorders


History of anxiety & panic disorders

• Until recently, anxiety seen as expression of emotions (e.g. fear).

• Theorising now shifted to cognitive processes.• Phobia = specific intense fear avoidance

behaviours; phobias documented since Greek mythology.

• Hippocrates: First clinical description of phobia.• Accounts of phobia found throughout writing of

philosophers, religious writers, playwrights.• Term ‘phobia’ entered psych lit late 1800s. • ‘Panic’ used since 1603; derived from the

mythological Greek deity, Panikos (Pan).• DSM-III (1980) recognised both Panic Disorder With

and Without Agoraphobia.


Clinical picture

DSM-5

Anxiety Disorders Obsessive-Compulsive and Related Disorders

Disorders

Trauma- and Stressor -Related Disorders

Separation Anxiety Disorder

Selective Mutism

Specific Phobias

Social Anxiety Disorder

Panic Disorder

Agoraphobia

Generalized Anxiety Disorder

Obsessive- Compulsive Disorder

Body Dysmorphic Disorder

Hoarding Disorder

Trichotillomania

Excoriation

Reactive Attachment Disorder

Disinhibited Social Engagement Disorder

Posttraumatic Stress Disorder

Acute Stress Disorder

Adjustment Disorder


Anxiety Disorders

Section 1


Introduction• In previous editions of the DSM, the anxiety

disorders (e.g. Generalized Anxiety Disorder, Panic Disorder and Phobias), obsessive-compulsive disorders and stress related disorders were all grouped together in one category, Anxiety Disorders.

• In the DSM-5, these disorders are now split into three distinct categories, however, the sequential order of these chapters in DSM-5 reflects the close relationships (the presence of anxiety) among them.

• The anxiety and stress related disorders make up the most common categories of mental disorders.


Separation Anxiety Disorder• In previous editions of the DSM disorders that are common in children

were classified in the section ‘Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence’, however, in the DSM-5 many of the disorders that were in this category were moved to other sections.

• Although this disorder is primarily diagnosed in children, the criteria do allow for this this diagnosis to be made in adults as well. The core feature of this disorder is extreme distress when an individual is separated from other people to whom she / he are attached.

• The distress is not necessarily limited to a real, physical separation, but may also be related to anticipated separation or persistent worry about losing a major attachment figure (APA, 2013).

• The disorder also manifests in a number of behavioural and physical symptoms.

• A person suffering from this disorder may be reluctant, or refuse, to go away from home or being alone without a major attachment figure.

• They may experience recurrent nightmares (related to separation) and physical symptoms (e.g. headaches, stomach aches, etc.,), the latter being evident when separation occurs or is anticipated (APA, 2013).


Specific Phobias• Formerly called ‘simple phobias’, the Specific Phobias typically refer to a

clearly recognisable situation or object (often inanimate) that the person fears (unlike Agoraphobia with its many feared situations).

• Craske (2003) defines Specific Phobias as the marked and persistent fear of clearly discernable and circumscribed objects or situations.

• When a person with a Specific Phobia encounters the feared situation or object, they may experience intense and immediate anxiety that could reach the levels of a full-blown Panic Attack.

• For example, someone who never goes to the doctor for fear of being close to needles, or someone who refuses to walk on the beach for fear of encountering a crab, may have a Specific Phobia. Such a person is likely to become anxious and apprehensive at the mere suspicion that they will come across the specific situation or object, and will often make a concerted effort to avoid any contact with it.

• It is not unheard of for a person with a severe phobia of snakes, for instance, to avoid paging through wildlife magazines for fear of seeing a photograph of a snake on its pages.


Specific Phobias cont.• Beck (2005a) contends that many fears are innate and that they

played an important protective function in the early years of human development.

• Certainly, the fear of some situations or objects has held survival value for human beings and has been selected during evolution (Barlow, 2004).

• It is, for instance, adaptive to fear and avoid jumping into a rough sea alone (especially if you are a non-swimmer) or picking up brightly coloured snakes (which are likely to be poisonous).

• However, with repeated exposure to many dangers, an adaptive mechanism may develop.

• Firefighters who have trained to fight fires, for example, may experience less anxiety than would other people, even in ‘high risk’ situations.

• This may be linked to the heavy reliance on behavioural and cognitive-behavioural treatments favoured for anxiety (Craske & Barlow, 2007).


• The maladaptive fears characteristic of phobias are typically unreasonable or excessive (Beck, 2005b).

• Adults are able to recognise that their phobic fears are out of proportion to the potential threat of the situation or object, or that they are simply illogical, while children will not necessarily have insight into this.

• However, this ‘danger value’ tends to dominate a phobic person’s appraisal of a situation (not objectivity) and they are likely to estimate greater harm from the situation or object as they approach it.

• Common examples of feared objects or situations are: • Animal type: dogs, mice, snakes, spiders, moths, worms• Situational type: driving in a car, flying in an airplane, elevators,

tunnels, bridges, enclosed spaces• Natural environment type: heights, water, thunder, lightning• Blood-injection-injury type: blood, injection needles, medical

practitioners, hospitals, someone else’s injury.

Specific Phobias cont.


• People with a Specific Phobia typically experience sympathetic nervous system arousal that causes an alarm response and resultant physiological changes such as increased heart rate, blood pressure, respiration, and perspiration as described above.

• They react to the phobic situation (e.g. airplane) or object (e.g. mouse) as if it were a truly life-threatening danger that they have to be prepared to either fight or flee.

• People with a blood-injection-injury type phobia, however, exhibit different and unusual physiological reactions.

• They typically experience marked decreases in heart rate and blood pressure when encountering their feared situation or object and very often faint as a result.

• This does seem counterproductive if the fear or anxiety component of these disorders is a false alarm of preparation for better survival responses.

Specific Phobias cont.


Social Anxiety Disorder (Social Phobia)

• Social Anxiety Disorder is not the fear of a specific situation or object, but rather the fear of scrutiny and evaluation by others or being embarrassed in front of others.

• It is defined as an excessive fear of social performance situations in which embarrassment is feared (Craske, 2003).

• For most people, being judged or embarrassed in social situations (especially in front of important others) is an unpleasant experience.

• Having to speak in public or perform an activity while being closely watched or evaluated is also not a favoured activity for most.

• However, those who have this disorder exhibit more than moderate nervousness and may experience a full-blown Panic Attack in a social performance situation.

• They have also been found to believe that everyone judges and criticises the performance skills of others (Turk, Heimberg, & Magee 2007).


Social Anxiety Disorder (Social Phobia) cont.

• The socially phobic individual strongly wishes to avoid being observed or judged by others but, if this should occur, they are likely to experience anxiety, increased perspiration, heart palpitations, trembling and shaking, dizziness, and confusion.

• People with Social Anxiety Disorder may avoid doing simple things such as eating or drinking with others, writing in front of others, or even using public toilets.

• The more complex the social task at hand, however, the more likely it is for the phobia to impair performance.

• Socially anxious people often believe that others will be able to notice the signs of their anxiety (although these are mostly more subjective than observable) and will judge them for it.


Panic disorders

• Frequent Panic Attacks (PA) = Panic Disorder.• PA can occur independently or as part of another

anxiety disorder.• Single episode Panic Attacks are not a disorder.• Ancient alarm system (fight/flight) + inappropriate

and dysfunctional learning.• ‘True alarm’ is functional; ‘false alarm’ is

disordered.


An open setting such as a shopping mall can be a trigger for Agoraphobia.


Panic disorders, cont.

• Recurrent panic attacks, with anxiety and fear of having more attacks.

• Irregular and unpredictable attacks.• Onset: Late adolescence to mid-thirties.• Often mistaken for a medical condition

(e.g. heart attack).

• DSM-5 subtypes of Panic Attacks• Cued: Situationally bound PA • Uncued: Unexpected PA • Situationally predisposed PA


Panic disorders, cont.

As the symptoms of Panic Attach are often mistaken for medical conditions such as heart attack, medical teams often identify patients with Panic Disorder.


Agoraphobia• Fear of public places, or a place that cannot easily

be escaped from.• Acquired fear of bodily sensations resembling a

PA. • Extreme cases limit sufferer to home.• Role of cognition and expectations important to

treatment.• Women twice as likely as men to develop

disorder.• High co-morbidity.


Phobias, cont.


Generalised Anxiety Disorder (GAD)

• Chronic anxiety, unfocused, excessive, with uncontrollable worry, and bodily symptoms.

• Worry about minor and major life issues.• Symptoms: Restlessness, irritability, chronic muscle

tension, difficulty concentrating, disturbed sleep, and possible physical problems.

• Common, chronic course, affects more women.• High co-morbidity (NB with mood disorders).• Early onset (childhood/adolescence).• Disagreement over excessive worry as necessary

symptom.• Diagnostic criteria for Overanxious Disorder of

Childhood are similar to GAD.


OBSESSIVE-COMPULSIVE DISORDER

AND RELATED DISORDERS

Section 2


Introduction• As has been mentioned before, Obsessive-Compulsive Disorder was

categorized as an Anxiety Disorder in the previous DSM’s.

• This disorder was characterised by the presence of both obsessions and compulsions, however, this approach was restrictive as there are a number of disorders that are characterised by only obsessions or compulsions.

• A new category, i.e. Obsessive-Compulsive and Related Disorders, was created in the DSM-5 and all disorder with obsessions, compulsions or both, were included in this category.

• The disorders in this category are related to one another in terms of a range of diagnostic validators, as well as the clinical utility of grouping these disorders.

• Obsessive-Compulsive Disorder has been moved from Anxiety Disorders to this category, and a number of new disorders have been introduced in this category, for example hoarding disorder and excoriation (skin-picking) disorder, and other disorders such as trichotillomania and Body Dysmorphic Disorder has been moved from other DSM-IV categories to this category.


Obsessive-Compulsive Disorder

• OCD classified as an anxiety disorder because people with OCD suffer anxiety due to their obsessions and compulsions.

• DSM-IV-TR diagnostic criteria require either obsessions, compulsions, or both.

• Obsessions: • Intrusive, persistent, and anxiety-provoking

thoughts, images, or impulses• that person is unable to control• but recognise to be irrational.


Obsessive-Compulsive Disorder, cont.

• Compulsions:• Repetitive mental acts or behaviours• that individual feels compelled to do• to relieve obsessions and the anxiety they

produce.• People do not usually carry out their obsessive

impulses, but feel anxiety and guilt over them.• Compulsions can become extreme and

debilitating, or dangerous.• Compulsions only temporarily calm anxiety.• Childhood onset.• Runs chronic course if not treated.


Body Dysmorphic Disorder• Body Dysmorphic Disorder primarily concerns the

preoccupation with a perceived bodily abnormality. • Facial features are the most common focus of concern, but

more than one body region can elicit attention. • Concerns can be specific or vague. • Mirror checking or avoidance, repetitive grooming, and

attempts to hide deformities are common compulsive features. • Concerns about a perceived bodily deformity can reach

delusional intensity. It is interesting to note than men and women share many of the clinical features such as disliked body areas, types of repetitive behaviours, etc., however men are more likely to have genital preoccupations and women more likely to have a comorbid eating disorder (APA, 2013).


Body Dysmorphic Disorder• Depression and anxiety are common in the history

and mental state examination, and psychosocial dysfunction can be severe.

• Suicide attempts are not uncommon. Common co-morbid conditions are major depression and anxiety disorders.

• Perfectionist, schizoid and narcissistic personality traits are also found.

• An insidious onset is characteristic and it runs a chronic course with fluctuating symptoms (Hales, 2008; Sadock & Sadock, 2000).


Hoarding Disorder• In the DSM-IV hoarding was listed as one of the possible symptoms of obsessive-

compulsive personality disorder and it was noted that extreme hoarding may occur in obsessive-compulsive disorder.

• However, reviewing available data seemed to indicate that there are sufficient symptoms to warrant a separate disorder and not just a variant of obsessive-compulsive disorder or another mental disorder.

• The core feature of this disorder is a persistent difficulty dis carding or parting with possessions due to a perceived need to save the items and distress associated with discarding them (APA, 2013).

• The hoarding is excessive to such an extent that that the resulting clutter “…impairs basic activities such as: moving through the house, cooking, cleaning, personal hygiene, and even sleeping” (APA, 2013, p.250).

• Hoarding disorder may have unique neurobiological correlates, but is not diagnosed if the disorder is the direct consequence of a degenerative disorder (e.g. frontotemporal lobar degeneration or Alzheimer’s disease) (APA, 2013).

• People with this disorder often have comorbid disorders such as major depressive disorder, social anxiety disorder, generalized anxiety disorder or OCD.


Trichotillomania (Hair-Pulling Disorder)• Trichotillomania was included in DSM-IV, although “hair-pulling

disorder” has been added parentheti cally to the disorder’s name in DSM-5.

• The essential feature of this disorder is the recurrent pulling out of one’s hair, which may be from any area of the body where hair grows.

• These sites may vary over time and typically occurs in brief episodes during the day.

• The disorder may endure for months and years and is associated with both distress and social and occupational impairment (APA, 2013).

• Not only could the disorder lead to irreversible hair growth, but also associated physical problems (e.g. carpal tunnel syndrome, shoulder, back and neck pain, and trichophagia) (APA, 2013).

• The disorder seems to have a genetic vulnerability to this disorder and it is commonly associated with OCD.


Excoriation (Skin-Picking) Disorder

• Excoriation (skin-picking) disorder is newly added to DSM-5, with the essential feature of this disorder being picking at one’s own skin.

• The skin picking is not limited to a particular body site and people with this disorder may pick at healthy skin or at minor skin irregularities (e.g. pimples, calluses, scabs, etc.).

• It often involves rituals (e.g. searching for particular kind of scab, pulling, examining, playing or swallowing the skin after it has been pulled) and is often triggered by an emotional state (e.g. anxiety, boredom, etc.)

• There seems to be a genetic vulnerability to this disorder and it is often associated with OCD and OCD-related disorders (APA, 2013).


Trauma- and Stressor-Related Disorders

Section 3


Stress disorders• Caused by stressful/traumatic life event/s.

Viv O'Neill

I think this one should go earlier? The text refers to firefighters under specific phobias.


Reactive Attachment Disorder• This disorder is one that is limited to infancy (at least 9 months old) or early

childhood (evident before the age of 5 years).

• The disorder is the result of extremes of insufficient care such as social neglect or deprivation, repeated changes of primary care givers or contexts where there are limited opportunities to form stable attachments.

• This results in a consistent pattern of inhibited, emotionally withdrawn behaviour toward adult caregivers such as not seeking comfort when distressed or not responding to comfort when provided.

• The child also exhibits persistent social and emotional disturbances such as limited responsiveness, limited positive affect and periods of unexplained irritability, sadness or fearfulness (APA, 2013).

• It is generally accepted that children with this disorder have the capacity to form attachments; however, due to their environments they have not been given the opportunity to do so (APA, 2013).

• The main cause of this disorder is serious neglect, however, what is of note is that not all children that are exposed to extreme neglect, develop this disorder (APA, 2013).


Disinhibited Social Engagement Disorder• In this case a child actively approaches and interacts with unfamiliar

adults in an impulsive, incautious, and overfamiliar way.

• As was the case with the previous disorder, this disorder also seems to be the result of extreme neglect before the age of 2 years (APA, 2013).

• This disorder, which is also limited to children, can almost be described as the inverse of Reactive Attachment Disorder (RAD).As opposed to RAD, children with this disorder readily approach strangers without fear and with excessive familiarity.

• This familiarity includes a readiness to hug and accept comfort, food or toys from an unknown person (APA, 2013).

• As is the case with RAD, serious social neglect is a diagnostic requirement for this disorder, but again, not all seriously neglected children develop this disorder.

• Although unconfirmed, it seems as if children who develop this disorder may have a neurobiological vulnerability to this disorder (APA, 2013).


Posttraumatic Stress Disorder (PTSD)

• The diagnosis of PTSD requires that a person presents with a set of symptoms following exposure to a traumatic event.

• The person would have to meet a certain minimum number of each of the following three categories of symptoms:• Re-experiencing the traumatic event• Avoiding associated stimuli, or emotional numbing and

detachment• Hypervigilance and chronic arousal.


Stress disorders, cont.


Stress disorders, cont.

Posttraumatic Stress Disorder (PTSD), cont.• Three key groups of symptoms:

• re-experiencing traumatic event• avoiding associated stimuli; emotional numbing

and detachment• hypervigilance and chronic arousal

• Guilt, shame, grief, distorted cognitions.• Resilience: Most people exposed to traumatic events

will not develop PTSD.• Research focus on harmful effects of trauma

exposure obscures possibility of Posttraumatic Growth (PTG) (e.g. research with veteran populations).


Acute Stress Disorder

• Same symptoms as PTSD.• Experienced for a shorter time period following the

trauma:• symptoms occur within one month• symptoms last no longer than four weeks


Adjustment Disorders• Adjustment disorders were previously a separate category in the DSM-IV-TR,

but it has now been reconceptualised in the DSM-5 as a stress-response syndrome, and therefore fits into the category of Trauma- and Stressor-Related Disorders.

• Previously these disorders were almost seen as residual disorders, i.e. where a person did not meet the clinical threshold for other disorders such Major Depression, Generalized Anxiety Disorders and the likes.

• In essence these disorders are seen to be emotional or behavioural responses to an identifiable stressor (APA, 2013).

• The response may be due to a single (e.g. divorce) or multiple stressors (cumulative stressful life events).

• Furthermore, these stressors may be recurrent or continuous, and may affect only the individual or groups such as families or communities (APA, 2013).

• The stressor can take on any form such as interpersonal difficulties, natural disasters, health, financial, family or work problems.

• Typically the disorder develops within three months of the onset of the stressor and lasts no longer than six months after the stressor has ceased (APA, 2013).


Cross-cultural and African perspectives

• People interpret psychological events from within their cultural framework.

• Cultural variation of anxiety symptoms worldwide.• Western values may limit cross-cultural research.• Psychology historically emphasised empirical,

positivist understandings of people – need to also draw on qualitative research.

• Collectivist as well as individualist cultural perspectives need to be considered.

• Need to take note of cultural context rather than assume Western understanding of symptoms is universal.


Cross-cultural and African perspectives, cont.

Imagine that the young women are American psychology students visiting South Africa and consider the amount of cultural knowledge they would need to gain to be able to work here.


Cross-cultural and African perspectives, cont.

• In SA, important to acknowledge multicultural influences.

• Unique presentation of culture-bound syndromes.• Anxiety disorders common in SA but data needed on

prevalence and incidence across cultural groups.• Linked to high crime rate; exposure to trauma in SA. • Sexualised violence (rape/sexual abuse) is NB

problem in SA.• Rape Trauma Syndrome (RTS) - similar to PTSD.• High incidence of motor vehicle accidents; may

Acute Stress Disorder.• Repeated trauma can either resilience or

compounded vulnerability.


Aetiology

• Factors (e.g. genetic) predispose person to anxiety disorders, but they only develop if stressor occurs.

• Diathesis-stress model: Vulnerability + Stressor• Stressor precipitates disorder.• Other factors maintain/perpetuate the disorder.• Factors:

• biological (e.g. neurochemical)• psychological (e.g. temperament)• social (e.g. poverty)


Aetiology, cont.

Biological perspectivesGenetics• NB for Panic Disorder and phobias.• Inherited tendency towards anxiety (temperament).• In SA, found COMT gene to contribute to OCD.

Brain structure and functioning• Stress causes permanently altered brain function,

especially in HPA axis and CRF neurons .


Aetiology, cont.

Biological perspectives, cont.Neurochemistry• Norepinephrine, serotonin, GABA, and

cholecystokinin (CKK) believed to play a role in Panic Disorder.

• Serotonin system functioning related to OCD.• Limbic system involved in the physiological and

emotional responses to threat.• In Panic Disorder, person may have over-

reactive autonomic nervous system.• Those with GAD, also thought to have insufficient

neurotransmitter GABA.


Aetiology, cont.

Psychological perspectivesPsychodynamic• Unconscious anxiety displaced into object or

symbol.• GAD a result of inadequate defence mechanisms.

Humanistic• People grow up with conditional positive regard.• Existentialists perceive GAD as a result of not

dealing with existential issues in life.


Aetiology, cont.Behavioural• Classical and operant conditioning.• Evolutionary response explains certain phobias.• Can occur through:

• direct association• vicarious learning• or information transmission

• Historically, exposure-based psychological interventions considered most effective for anxiety.

• ‘Mindfulness’ and ‘Acceptance-based’ approaches also show promise with certain anxiety disorders.


Aetiology, cont.Cognitive • Social phobia develops from negative beliefs and

cognitive biases (NB in post-event processing).• GAD develops from cognitions related to threat.• Panic Disorder involves cognitions related to:

• physical sensations• negative misinterpretation of sensations• catastrophic thinking (exaggerations)

• Heightened awareness of body cues can increase anxiety and exacerbate panic.

• OCD obsessions develop through:• rigid, moralistic thinking• difficulty tolerating uncertainty


Aetiology, cont.

Personality and temperament• Shy or timid; more prone to anxiety.• Negative affectivity and threat-based styles of

emotion explain vulnerability to disorder.


Aetiology, cont.

Psychosocial stressors• Stress disorders arise in direct response to stressor.• Individual vulnerability and coping capacity play a

role in occurrence and severity of maladaptive stress reactions.

• Individual proximity directly related to risk of developing PTSD.

Familial perspectives• Through observational learning (e.g. of their

parents), children may learn to respond with fear/anxiety.


Aetiology, cont.

Socio-cultural perspectives• Environmental demands on people influence

predisposition to disorder.• Social and cultural norms (and gender) influence

presenting with and/or admitting to symptoms.• Sex-role socialisation men and women respond

differently to distress.


Aetiology, cont.

Integrated perspectives• All factors are likely to interact.• ‘Triple vulnerability theory’: Vulnerability factors

interact to cause disorder:• genetic• psychological• early learning experiences


Conclusion

• Limited consensus over classification of anxiety disorders.

• Further changes in classification and prevalence to be expected.

• Multiple influences of gender, culture, ethnicity, etc. on symptom presentation.

• Aetiological knowledge still growing.• Need broader explanatory models,

acknowledging risk (or vulnerability) factors, as well as resilience (or protective) factors.

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Chapter 4 (revised)

Education