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ANXIETY DISORDERS

Anxiety and fear play significant role in this group of disorders

NATURE OF ANXIETY AND FEAR
Anxiety is a negative mood state characterized by bodily symptoms of physical
tension and by apprehension about the future
Future-oriented
marked negative affect
Somatic symptoms of tension
Apprehension about future danger or misfortune
Fear is an immediate alarm reaction to danger.
Present-oriented mood state, marked negative affect
Immediate fight or flight response to danger or threat
avoidance/escapist behaviour
Anxiety and Fear are Normal Emotional States
From Normal to Disordered Anxiety and Fear
Characteristics of Anxiety Disorders
Persistent symptoms of anxiety and fear
Involve excessive avoidance and escapist tendencies
Causes clinically significant distress and impairment
Generalized Anxiety Disorder
People with generalized anxiety disorder experience excessive anxiety under
most circumstances and unproductive worrying about everyday events.
.
Diagnostic Criteria
A. Excessive anxiety and worry (apprehensive expectation) about a number of events
or activities (such as work or school performance).
B. The person finds it difficult to control the worry.
C. The anxiety and worry are associated with at least three (or more) of the following
six symptoms
1. Restlessness or feeling keyed up or on edge
2. Being easily fatigued
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance (difficulty falling or staying asleep or restless, unsatisfying
sleep)
Causes
Generalized biological-vulnerability
Generalized psychological vulnerability.
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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).
Significant stress makes them apprehensive and vigilant. This sets off intense worry
with resulting physiological changes, leading to GAD.

Specific Phobia: An Overview

A phobia (from the Greek word for fear) is a persistent and unreasonable fear
of a particular object, activity, or situation. People with a phobia become fearful if
they even think about the object or situation they dread, but they usually remain
comfortable as long as they avoid it or thoughts about it.
1. Marked, persistent, and disproportionate fear of a particular object or situation, usually
lasting at least 6 months.
2. Exposure to the object produces immediate fear.
3. Avoidance of the feared situation.
4. Significant distress or impairment. (APA, 2013)
Specific Phobia: Subtypes
Blood-injury-injection phobia
Situational phobia - Public transportation or enclosed places (e.g., planes)
Natural environment phobia - Events occurring in nature (e.g., heights, storms)
Animal phobia - Animals and insects
Other phobias - Do not fit into the other categories (e.g., fear of choking,
vomiting)
Causes of Phobias
Biological and evolutionary vulnerability, direct conditioning, observational
learning, information transmission
Social Phobia
Severe, persistent, and irrational anxiety about social or performance situations in which they
may face scrutiny by others and possibly feel embarrassment (APA, 2013).
Criteria
1. Pronounced, disproportionate, and repeated anxiety about social situation(s) in which the
individual could be exposed to possible scrutiny by others, typically lasting 6 months or
more.
2. Fear of being negatively evaluated by or offensive to others.
3. Exposure to the social situation almost always produces anxiety.
4. Avoidance of feared situations.
5. Significant distress or impairment. (APA, 2013).
Generalized type - Anxiety across many social situations; extremely and painfully shy in
almost all social situations
Facts and Statistics
Affects about 13% of the general population at some point
Females are slightly more represented than males
Onset is usually during adolescence
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Peak age of onset at about 13 years

Social Phobia: causes

Biological and evolutionary vulnerability
Direct conditioning, observational learning, information transmission
Agoraphobia
Fear or avoidance of situations/events where escape might be difficult or help
unavailable.
Typical Situations Avoided
Shopping malls Being far from home, Cars (driver /passenger) Staying at
home alone, Buses, Waiting in line, Trains, Supermarkets, Subways, Stores,
Wide streets, Crowds, Tunnels, Planes, Restaurants, Elevators, Theatres,
Escalators.
Panic Attack
Abrupt experience of intense fear or discomfort Accompanied by several physical
symptoms (usually include heart palpitations, chest pain, shortness of breath, and,
possibly, dizziness)
Diagnostic Criteria for Panic Attack
The predominant complaint is a discrete period of intense fear or discomfort in which
at least four (or more) of the following symptoms developed abruptly and reached a
peak within 10 minutes:
1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, lightheaded, or faint
9. Derealization (feelings of unreality) or depersonalization (being detached from
oneself)
10. Fear of losing control or going crazy
11. Fear of dying
12. Paresthesias (numbness or tingling sensations)
13. Chills or hot flushes
Panic Disorder:
An anxiety disorder marked by recurrent and unpredictable panic attacks
1. Unforeseen panic attacks occur repeatedly.
2. One or more of the attacks precedes either of the following symptoms:
(a) At least a month of continual concern about having additional attacks.
(b) At least a month of dysfunctional behavior changes associated with the
attacks (for example, avoiding new experiences) (APA, 2013).
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Panic with agoraphobia. If it causes panic attack.

Associated Features and Treatment

Nocturnal panic attacks - 60% panic during non-REM sleep
Interoceptive/exteroceptive avoidance,
Catastrophic misinterpretation of symptoms
Biological Contributions to Anxiety and Panic
Diathesis-Stress
Inherit vulnerabilities for anxiety and panic, not disorders
Stress and life circumstances activate vulnerability
Psychological Contributions to Anxiety and Fear
Began with Freud
psychic reaction to danger
reactivation of an infantile fear situation
Behavioristic Views
classical and operant conditioning and modeling
Psychological Views
Early experiences with uncontrollability / unpredictability
Social Contributions
Stressful life events trigger vulnerabilities
Many stressors are familial and interpersonal
Toward an Integrated Model
Integrative View
Biological vulnerability interacts with psychological, experiential, and social
variables to produce an anxiety disorder
Consistent with diathesis-stress model
Common Processes
The Problem of Comorbidity
Comorbidity is common across the anxiety disorders
About half of patients have 2 or more secondary diagnoses
Major depression is the most common secondary diagnosis

Medication Treatment of Panic Disorder
Prozac and Paxil - Preferred drugs
Relapse rates are high following medication discontinuation
Cognitive-behavior therapies are highly effective
Trauma- And Stressor-Related Disorders
Disorders in which exposure to a traumatic event is followed by significant stress reactions.
Posttraumatic Stress Disorder (PTSD)
A disorder in which a person continues to experience fear and related
symptoms long after a traumatic event.
Experiences extreme fear, helplessness, or horror
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Continue to re-experience the event. The traumatic event is persistently re-

experienced in one (or more) of the following ways:
1. Recurrent and intrusive distressing recollections of the event, including images,
thoughts, or perceptions.
aspects of the trauma are expressed
2. Recurrent distressing dreams of the event. Note: in children, there may be
frightening dreams without recognizable content
3. Acting or feeling as if the traumatic event were recurring (includes a sense of
reliving the experience, illusions, hallucinations, and dissociative flashback episodes,
including those that occur on awakening or when intoxicated).
4. Intense psychological distress at exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event
5. Physiologic reactivity on exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event
Avoidance of anything that reminds of the trauma
Restriction or numbing of emotional responsiveness by avoiding thoughts, feelings
or conversations associated with the trauma. Inability to recall an important aspect of
the trauma.
Persistent symptoms of increased arousal (any two of the following)
1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Hypervigilance
5. Exaggerated startle response
Markedly interferes with one's ability to function
PTSD diagnosis - Only I month or more post-trauma
Facts and Statistics
Affects about 7.8% of the general population
Most Common Traumas
Sexual assault
Accidents
Combat
Obsessive-Compulsive and Related Disorders
Characterized by persistent and uncontrollable thoughts or urges or images (obsessions) and
by the need to repeat certain acts (compulsions).
Most persons display multiple obsessions
Many cleaning, washing, and/or checking rituals
Criteria
A. 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 unwanted, and that in most individuals
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cause marked anxiety or distress.

2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to
neutralize them with some other thought or action (i.e., by performing a compulsion).
Compulsions are defined by (1) and (2):
1. Repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g.,
praying, counting, repeating words silently) that the individual feels driven to per-
form in response to an obsession or according to rules that must be applied rigidly.
2. The behaviours or mental acts are aimed at preventing or reducing anxiety or distress, or
preventing some dreaded event or situation; however, these behaviours or
mental acts are not connected in a realistic way with what they are designed to neutralize or
prevent, or are clearly excessive.
B. 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.
Specify if:
With good or fair insight: The individual recognizes that obsessive-compulsive dis-
order 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 beliefs: The individual is completely convinced that
obsessive-compulsive disorder beliefs are true.
Hoarding Disorder : Diagnostic Criteria
A. Persistent difficulty discarding or parting with possessions, regardless of their actual
value.
B. This difficulty is due to a perceived need to save the items and to distress associated with
discarding them.
C. The difficulty discarding possessions results in the accumulation of possessions that
congest and clutter active living areas and substantially compromises their intended use.
D. The hoarding causes clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
E. The hoarding is not attributable to another medical condition (e.g., brain injury,
cerebrovascular disease).
F. The hoarding is not better explained by the symptoms of another mental disorder (e.g.,
obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder,
delusions in schizophrenia or another psychotic disorder, cognitive deficits in major
neurocognitive disorder, restricted interests in autism spectrum disorder).
Body Dysmorphic Disorder : Diagnostic Criteria
A. Preoccupation with one or more perceived defects or flaws in physical appearance that are
not observable or appear slight to others.
B. At some point during the course of the disorder, the individual has performed repetitive
behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or
mental acts (e.g., comparing his or her appearance with that of others) in response to the
appearance concerns.
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C. The preoccupation causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning.
D. The appearance preoccupation is not better explained by concerns with body fat or weight
in an individual whose symptoms meet diagnostic criteria for an eating disorder.
Trichotillomania (hair-pulling disorder) is characterized by recurrent pulling out of one's
hair resulting in hair loss, and repeated attempts to decrease or stop hair pulling.
Excoriation (skin-picking) disorder is characterized by recurrent picking of one's skin
resulting in skin lesions and repeated attempts to decrease or stop skin picking.
The body-focused repetitive behaviours that characterize these two disorders are not
triggered by obsessions or preoccupations; however, they may be preceded or accompanied
by various emotional states, such as feelings of anxiety or boredom. They may also be
preceded by an increasing sense of tension or may lead to gratification, pleasure, or a sense
of relief when the hair is pulled out or the skin is picked. Individuals with these disorders may
have varying degrees of conscious awareness of the behaviour while engaging in it, with
some individuals displaying more focused attention on the behaviour (with preceding tension
and subsequent relief) and other individuals displaying more automatic behaviour (with the
behaviours seeming to occur without full awareness).
Facts and Statistics
Affects about 2.6% of the population at some point
Most persons with OCD are female
OCD tends to be chronic
Onset is typically in early adolescence or adulthood

Causes of OCD
Parallel the other anxiety disorders
Early life experiences and learning that some thoughts are dangerous/unacceptable
Thought-action fusion equating thought with action
Treatment
Medication Treatment of OCD
Clomipramine and other SSRIs Benefit about 60%
Psychosurgery (cingulotomy) Used in extreme cases
Relapse is common with medication discontinuation
Psychological Treatment of OCD
Cognitive-behavioral therapy Most effective for OCD
CBT involves exposure and (ritual) response prevention
Scrupulosity has been described as a psychological disorder primarily characterized by
pathological guilt or obsession associated with moral or religious issues that is often
accompanied by compulsive moral or religious observance and is highly distressing and
maladaptive. Those afflicted with scrupulosity fear that their effort to live according to their
spiritual values not only isnt good enough, but is in direct violation of God.
-Compulsive Confession & restitution seeking
-Pathological doubt and questioning
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Ref. Scrupulosity: Where OCD Meets Religion, Faith, and Belief ocdla.com/scrupulosity-ocd-
religion-faith-belief-2107 By OCD Center of Los Angeles, 2013.
Perfectionism is a personality trait characterized by a person's striving for flawlessness and
setting excessively high performance standards, accompanied by overly critical self-
evaluations and concerns regarding others' evaluations. Perfectionists are prone to strive for
unrealistic goals and feel dissatisfied when they cannot reach them.
Perfectionism should be distinguished from "striving for excellence" in particular with regard
to the meaning given to mistakes. Those who strive for excellence can take mistakes
(imperfections) as incentive to work harder. Perfectionists consider their mistakes a sign of
personal defects. (Potential) failure causes anxiety and affects the self-esteem.

Ref. Roopikaranabhashyam vol.8, no.2,2013; Clinical Psychology Review vol. 2, no. 6, pp.
879-906