Chapter 4: Anxiety, Obsessive-Compulsive and Trauma- and Stressor-Related Disorders
Anxiety – a common emotion characterised by physical symptoms (faster heartbeat, feelings of tension) and thoughts
or worries that something bad will happen.
What is Anxiety?
It is a future-oriented response, which often occurs when people encounter a new situation or anticipate a life-
The Flight-or-Fight Response
Your hypothalamus (the part of the brain responsible for recognizing threatening situations and coordinating your
response) sends a message to your adrenal glands to release the hormone adrenaline.
Your body’s response, called fight or flight was a general discharge of your SNS. It’s been part of human behaviour
since prehistoric times.
• Nervous system’s two parts: the CNS (brain and spinal cord) and Peripheral Nervous System (all other nerves in
• PNS’s two parts: 1. Somatic Sensory System – contains sensory and voluntary motor functions
2. Autonomic Nervous System – controls involuntary movements.
- Two parts: Sympathetic Nervous System and Parasympathetic Nervous
• When activated by stress or fear, the Sympathetic Nervous System (SNS) goes into overdrive; heart beats
faster than normal, supplying more blood to power the muscles. Respiration rate increases, allowing more oxygen
to get to your blood to power the brain. This fight-or-flight response allows an optimal level of physical functioning
in the face of threat.
• After the SNS has been activated, the Parasympathetic Nervous System (PNS) returns your body to its normal
resting state by decreasing your heart rate, blood pressure, and respiration.
• F-or-F usually associated with fear, a reaction to an existing or threatening event. The motivating power of F-or-F
allows you to use all available resources to escape from a threatening situation. Researchers describe the
reaction as an alarm to a present danger.
In contrast, anxiety is a future-oriented response and sometimes consists of decreased levels of physical reactivity
rather than the F-or-F response. Often it is characterized by a though pattern that is sometimes described as
imagining the worst possible outcome. Often present when there is no real danger.
The Elements of Anxiety
4.1: Identify the 3 Components of Anxiety
Panic Attack – an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and is
accompanied by four or more physical symptoms.
Three Distinct Components of Anxiety/Fear:
1. Physiological Response (blushing, buzzing/ringing ears, muscle tension, irritability, fatigue, gastrointestinal
distress, or urinary urgency or frequency; children: headaches, stomach-aches- older more likely to report physical
2. Cognitive Symptoms or Subjective Distress (specific thoughts, ideas, or impulses) – occurs when the affected
person sees a feared object or event or can occur spontaneously. Worry, also a cognitive symptom, is an
apprehensive (negative) expectation about the future that is considered to be unreasonable in light of the actual
situation. Exists among adults, adolescents, and children. Preadolescent children do not always report the
thoughts and worries that are common among anxious adults, which may reflect their overall cognitive immaturity;
developmentally they do not yet have the ability to “think about thinking” (Metacognition).
3. Avoidance or Escape Behaviour of the feared object, situation, or event. Avoidance can also take the form of
overdoing certain behaviours. E.g. fears of contamination result in excessive behaviours such as
washing/cleaning to eliminate the feeling. These behaviours bring temporary relief from distress, but also reinforce
behavioural avoidance though the process of negative reinforcement. E.g. By running away, you removed the
negative feeling of fear and you felt better. The relief that follows the removal of something negative is reinforcing;
this feeling increases the likelihood that the next time you enter a similar situation, you will run again. Therefore,
eliminating distress by avoiding distress by avoiding or escaping can actually make the anxiety worse. Psych
treatment for anxiety seeks to reverse this pattern of negative reinforcement and eliminate avoidance of the feared situations.
How “Normal” Anxiety Differs from Abnormal Anxiety
4.2 Distinguish between a normal fear response and these anxiety-based disorders.
4.3 Understand how developmental and sociocultural factors affect the expression of anxiety.
Factors to consider when anxiety becomes a disorder:
• Functional Impairment – affects daily life activity
• Developmental Age
• Among children, fears are common, and they follow a developmental trajectory.
• Two important aspects of the developmental model include the number and types of fears. The total number
of fears decline as age increases.
• Young children – new to world; it seems initially scary. Different fears are also common at different ages. As
children mature physically and cognitively, they stop fearing loud noises; begin to understand that noisy things
are not necessarily harmful.
• This developmental hierarchy of fear is not simply a matter of chronological age but also involves cognitive
development. When cognitively challenged, their fears usually reflect their cognitive development, not their
chronological (actual) age.
• Socio-demographic factors (sex, race/ethnicity, and socioeconomic status). In the general population, anxiety
disorders are more common among females than males, sometimes at a ratio of 3:1 for any particular anxiety
disorder. May reflect cultural and/or gender role expectations. Social acceptability may allow females to report
more fear, but they may not necessarily have more fears. In tests, girls report more, but physical symptom
measurements show boys and girls show equal increases. Even though more women report than men, the sex
distribution is more equal among people who seek treatment. Therefore, when fears are severe, men and women
are equally represented.
What Are the Anxiety Disorders?
4.4 Describe the critical elements that comprise each of the different disorders
• Anxiety Disorders have in common the physical, cognitive, and behavioural symptoms. For each, the anxiety
is expressed in a different way or is the result of a different object or situation.
• Some people are anxious in more than one type of situation, and in some cases they may have more than
one anxiety disorder. The co-occurrence of two or more disorders existing in the same person (either at the
same time or at some point in the lifetime) is called comorbidity. About 57% of people who are diagnosed
with an anxiety disorder are comorbid for another anxiety disorder or depression.
• In the US, 31.2% of adults suffer from one of these disorders (including OCD and PTSD) at some time in their
lives, making them one of the most common types of psych disorders among adults.
• Also common among children and adolescents around the world; prevalence ranges from 8.6 – 15.7%.
• Most anxiety disorders develop early in life; average onset is 11 years, one of the earliest for any psychiatric
• Anxiety disorders occur with equal frequency across the three largest ethnic groups in the US (Hispanics,
whites, and blacks).
• In addition to personal suffering, anxiety disorders compromise quality of life and social functioning, affect
educational attainment, and increase professional help seeking and medication use.
• Also exerts a substantial cost on society – in US approx $42.3 billion/yr.
PANIC ATTACKS • A discrete period of intense fear and physical arousal
• Develop abruptly, and symptoms reach peak intensity within minutes
• Somatic and cognitive symptoms of a panic attack may include heart palpitations (pounding or accelerated
heart rate), sweating, trembling, shortness of breath, choking, chest pain, nausea or abdominal distress,
dizziness, derealisation or depersonalisation (feeling of being detached from one’s body or surroundings), fear
of losing control or going crazy, feeling of dying, parethesias (tingling in hands or feet), and chills or heat
• Heart palpitations and dizziness are the most commonly reported symptoms, whereas paresthesias and
choking are the least common.
• As many as 28.3% of adults have had a panic attack during their lifetime, but having one does not mean
they have a panic disorder or any other anxiety disorder; only 4.7% actually have a panic disorder.
• NB: In an anxiety disorder, the anxiety symptoms must cause distress or functional impairment.
• When panic attacks are not isolated events, they may be a symptom of any of the anxiety disorders
• Even though only on the anxiety disorders actually has the word panic in the title, panic attacks may be a
symptom of other anxiety disorders and occur when a person is facing a frightening situation that is not a real
threat to their physical well-being. In other cases, the anxiety reaction may be out of proportion to the object or
• Panic attacks may be one of two types:
1. Expected Panic Attacks – occur in response to a situational cue or trigger or may occur in anticipation of
a feared situation.
2. Unexpected Attacks – out of the blue. Considered a False Alarm because no object, event, or situation
appears to precipitate the attack. Many misinterpret the attack as a heart attack and go to the hospital,
which suggest just how frightening these symptoms can be.
• Panic attacks are the defining feature of panic disorder.
• A person has had a least one panic attack and worries about having more attacks. They may also worry about
what a panic attack means and may behave differently in response to those attacks, such as calling the doctor
after every attack.
• Not everyone who is diagnosed changes their behaviour or avoids situations because of the fear that a panic
attack might occur, but some do.
• “Fear of the marketplace”; A marked or intense fear or anxiety that occurs upon exposure to, or in anticipation
of, a broad range of situations.
• The fear/anxiety must occur in at least two out of the five situations including:
• Public transportation, open spaces, enclosed spaces, standing in line or being in a crowd, or being
outside the home alone.
• Some can only enter these situations with a trusted companion or by carrying certain items in case a panic
• Also may fear the occurrence of extremely embarrassing physical symptoms such as dizziness or falling,
losing control of the bowels or bladder, or in children, a sense of disorientation or getting lost. • Many develop it after a panic disorder; they fear a panic attack may occur and they may be in a situation or
place where they might not be able to get help often leads to a pattern of behavioural avoidance.
• Not all with agoraphobia have panic attacks.
• Usually rare in young children and only slightly more common in adolescents; usually begins in early
adulthood. In adult population panic disorder (3.7%) is the most common of the three disorders.
• Whereas younger adults use the word fear when describing the emotion accompanying their physical
symptoms, older adults use the word discomfort – physicians must remember this distinction when
interviewing older adults in case of misdiagnosis and lack of appropriate treatment.
• More than 94% of people with panic disorder with/out agoraphobia seek treatment; without treatment,
symptom-free periods are rare. When a symptom-free period occurs, many relapse within a year.
• Even with medication treatment, panic attacks often decrease in frequency but are not eliminated. Five years
after receiving treatment, 85% of people no longer had panic disorder, although 62% still had occasional panic
• Women are most likely to experience panic attacks and panic disorder than men, and symptom variation
exists across cultural groups.
Ataque de nervois – found primarily among Latino people from the Caribbean. Some
symptoms (heart palpitations, trembling) are similar to typical panic symptoms, whereas
others (screaming uncontrollably, becoming physically aggressive) are specific to Ataque.
While panic attacks occur out of the blue typically, Ataque commonly occurs after social
disruptions such as a change in family status.
Khyal – occurs among Cambodian people characterized by typical panic attack symptoms
such as dizziness and culture-specific symptoms such as ringing in the ears and neck
Trung Gio – occurs among Vietnamese people “wind attacks”.
• People also often feel sad and depressed in part because their anxiety limits their daily functioning including
their ability to work and socialise. About 50% with panic disorder rely on financial assistance through
unemployment, disability, welfare, or Social Security Payments.
• People with panic disorder and personality disorders may have suicidal thoughts or attempt suicide. Most
researchers believe that the presence of the additional disorder increases the likelihood of suicidal behaviour.
GENERALIZED ANXIETY DISORDER
• Key feature is excessive anxiety and worry occurring more days than not and lasting at least 6 months.
• People with GAD worry about future events, past transgressions, financial matters, and their own health and
that of beloved ones. Children worry about their abilities or quality of their performance.
• In addition to being out of proportion to the actual situation, the worry is described as uncontrollable and is
accompanied by physical symptoms that include muscle tension, restlessness or feeling keyed up or on edge,
being easily fatigued, difficulty concentrating, sleep disturbance, and irritability.
• Cognitive symptoms include an inability to tolerate uncertainty and a belief that worrying may allow the person
to avoid and/or prevent negative consequences.
• They often say “I always find something to worry about,” and often have at least one other psychological
disorder, usually another anxiety disorder or major depression.
• However, the worries of people with GAD are more sever, they complain more frequently of muscle tension,
feeling restless, and feeling keyed up or on edge and they have lower levels of SNS arousal than people with
other anxiety disorders. These factors often help clinicians decide whether someone has GAD or a different
anxiety disorder. • More adults than children have GAD and it most commonly starts in the late teens through the late twenties.
GAD begins gradually and is usually a chronic condition.
• Even after pharmacological or psychosocial treatment, many people continue to have symptoms. Five years
after it begins, 72% still suffer from the disorder.
• Many seek treatment from primary care physicians; up to 12% who seek treatment from primary care
physicians do so because of GAD symptoms.
• Many people suffer from GAD; prevalence estimated range from 5% to 10% of community and clinic samples.
• Among children, the prevalence may be as high as 15% of the general population. They usually experience
feelings of tension and apprehension, negative self-image, and the need for reassurance. They also have
physical symptoms such as restlessness, irritability, concentration difficulties, sleep disturbance, fatigue,
muscle tension, and stomach-aches.
• Adolescents report more physical symptoms than children, and headaches are more common with them.
• GAD affects both sexes equally.
• Unexpected, negative, or very important life events are associated with the onset of GAD for both women and
• More common among racial/ethnic minorities and people of low SES (more realistic worries). Less certainty
regarding the availability of basic necessities may play a role in the onset of GAD.
Social Anxiety Disorder/ Social Phobia
• The third most common psychiatric disorder in the US.
• Marked fear of social situations which may involve scrutiny by others.
• Social situations that create distress include speaking, eating, drinking, or writing in the presence of others;
engaging in social interactions such as parties or meetings; and simply initiating or maintaining conversations.
• In such situations, they fear that others will detect their anxiety and that they will be evaluated negatively, be
rejected by, or will offend other people.
• Most with Social Anxiety Disorder have fear in most social interactions (public speaking, parties, and one-on-
• Diagnostically, there is a specifier called performance only, for people with social anxiety disorder when their
fears are limited to just a few situations (usually public speaking or performance situations). People with this
specifier typically have less sever anxiety and depressive symptoms, minimal or no social skills deficits, a later
age of onset, and a less frequent history of childhood shyness.
• More than half with social anxiety disorder have additional disorders, such as GAD, agoraphobia, panic
disorder, specific phobia, or PTSD as well as depression.
• May impai educational plans, advances in a career, work productivity, & socialisation with others.
• They often use alcohol to lessen their social distress, such as having a drink before a party, even though little
evidence shows that this actually reduces anxiety. Even so, many with Social Anxiety Disorder and alcohol
dependence report that their substance abuse or dependence developed as a result of their attempts to reduce
distress is social settings.
• Average onset 11-13 yrs; one of the earliest appearing anxiety disorders. Can be detected as early as 8yrs,
and 8% of adults report that their disorder began in childhood. When it begins in childhood, it is not likely to remit
without treatment; little probability of spontaneous recovery when it begins before age 11.
• Although it resolves without treatment, the symptoms may become better or worse depending on particular life
circumstances. An episode averages 18yrs in length compare to 6 yrs for panic disorder and 1 yr for major
depression. However, more than 85% of those with social anxiety disorder recover with psych treatment and
remain symptom free 10 yrs later. • Approx 3-5% of children and adolescents have it, as do 12-13% of adults; even those in the public limelight
can suffer from it.
• The situations that people fear are similar regardless of age.
• Since it’s a chronic condition, its impact becomes more pervasive and creates significantly more dysfunction
with age. This negative development trajectory begins in early childhood. Avoidance leads to a vicious cycle in
which limited social abilities increase the likelihood of negative social interactions, which in turn can increase
avoidance, resulting in few opportunities to achieve important developmental milestones.
• It affects both sexes equally and within the US, it occurs consistently across racial/ethnic groups.
Tajin Kyofusho – a condition found in Asian cultures, is sometimes considered a form of social
anxiety disorder; it occurs most frequently among young men. Those with it fear social interactions in fear
of offending and/or making others feel uncomfortable due to their inappropriate social behaviour or
perceived physical blemish/deformity. The focus on offending others may be based on Japanese culture,
which emphasises the importance of presenting oneself positively, and collectivism rather than
• Most commonly found in children; defined as a consistent failure to speak in specific social situations despite the
ability to speak and despite speaking in other settings.
• Typically they speak in their home with their immediate family. However, they do not speak outside the home or in
the presence of other individuals, sometimes they do not speak to their grandparents.
• Significant overlap with social anxiety disorder including the reason for fear, the situations in which the fear occurs,
and the treatments that are efficacious for the disorder
• A marked fear or anxiety about a specific object or situation that leads to significant disruption in daily functioning.
• A significant proportion of the general population admits to being fearful of something.
• Two criteria determine when the word phobia should be applied to a specific fear:
1. The symptoms cause significant emotional distress (even if one is bale to engage in the
2. Functional impairment.
• When fear creates marked distress or impairs an aspect of life functioning, it becomes a phobia.
• The diagnostic criteria include one of five specifiers:
- Animal phobias (animal/insect)
- Natural Environment phobias (fear of objects or events such as storms, heights, or water)
- Blood/Injection/Injury (B-I-I) phobias (fear of blood injuries, or needles). Unlike other phobias in which
associate physical responses reflect increased sympathetic nervous system activity, parasympathetic
activation dominated the characteristic response of B-I-I. People with these fears show vasovagal
syncope, defined as bradycardia (slow heart rate) and hypotension (low blood pressure) that can lead to
fainting. Reason for this unusual physical response is unclear- may be bio determined, perhaps the
evolutionary response to a serious physical injury. When someone is injured, decreases in heart rate and
blood pressure lead to decreased blood flow, which in turn enhances the person’s chances of physical
survival; this normal bio response is triggered inappropriately in those who fear blood or needles. - Situational phobias (fear of situations such as using public transportation, driving through tunnels or
bridges, riding elevators, flying, driving, or being in enclosed spaces). Fears of flying or enclosed places
(claustrophobia) are common. Because people with agoraphobia also report fears and avoidance of
certain situations, it is important to differentiate this disorder from specific phobias. People with a specific
phobia are afraid of some aspect of the situation itself (e.g. having an accident while driving), whereas
people with agoraphobia are afraid of having a panic attack while driving. Thus, while the physical and
cognitive symptoms may be the same, the object or situation that precipitates the symptoms differs.
- Other (used for fears unrelated to other groups).
• Common specific phobias among adults in US: seeing insects/snakes/birds/other animals; being in high places;
being in closed spaces.
• People often have more than one specific phobia, and often have other anxiety disorders.
• Even though these disorders are severe and disabling, few who suffer from them ever seek treatment unless the
situation becomes extreme.
• Common anxiety disorder, affecting 12.5% of adults and 3.5% of children in the US. Also common worldwide.
• Among people with a diagnosis of specific phobia, half have a fear of either animals or heights.
• Most specific phobias develop during childhood, with an average onset of 7 yrs.
• Commonly equal among African Americas, Hispanic whites, and non-Hispanic white adults.
• More common among girls than boys; more common among young children rather than adolescents.
• Women more likely to have situational, animal, and natural environment phobias.
• Men and women are equally likely to fear heights and B-I-I situations.
SEPARATION ANXIETY DISORDER
• Primarily affects preadolescent children; a developmentally inappropriate and excessive anxiety concerning
separation from someone to whom the child is emotionally attached.
• Child worries about being harmed or the care-giver being harmed. (Kidnapping, auto accident, or plane crash).
• When severe, the child may refuse to go to school or be physically separated from the parent, even at home.
• Child may insist on sleeping with the caregiver or may be unable to sleep overnight elsewhere; usually have
nightmares with themes of separation.
• Physical symptoms often accompany the worry and most commonly include headaches or stomach-aches.
• 3-5% of children suffer, but many recover within a short period of time.
• Girls more likely than boys to report separation fears.
• More common among children than adolescents.
• White, African American, and Hispanic children are equally likely to suffer.
• May also refuse to attend social activities such as birthday parties or to participate in sports unless their parents
accompany them and stay at the event.
• Emerging research on the existence of it among adults; among a large sample of adult outpatients with an anxiety
or mood disorder, 21% met criteria for it, which had not been present in childhood.
• It may precede the onset of many different types of anxiety disorders and depression, not just panic disorder. What Are the Obsessive-Compulsive and Related Disorders?
• Consists of obsessions (recurrent, persistent, intrusive thoughts) often combined with compulsions (repetitive
behaviours) that are extensive, time consuming, and distressful.
• Obsessions are usually specific thoughts, but they may also be urges or images – are usually also inappropriate,
and often abhorrent, and usually create substantial anxiety or distress.
• Those with OCD recognize that their obsessions are the product of their own minds and not imposed
upon them by someone else.
• Common obsessions include thoughts about dirt and germs; aggression; failure to engage locks, bolts,
and other safety devices; sex; and religion.
• Compulsions consist of repetitive behaviour that the person feels driven to do in response to obsessions or
according to rigid rules. They can be observable behaviours (e.g. washing hands) or mental activities (e.g. silent
• By completing the ritual, they feel they can prevent their obsessions from becoming reality.
• Compulsions are maintained by negative reinforcement; relief provided by carrying out the compulsion
temporarily feels good and increases the likelihood that the next time you feel experience the obsession,
you will carry out the compulsion again.
• In addition to hand washing, common compulsions include excessive bathing, cleaning, checking,
counting, and ordering possessions.
• Sometimes ppl are reluctant to discuss their Os and Cs, even with family; they perform rituals in secret, often in
the middle of the night. When severe, the compulsions can dictate all of the persons’ activities.
• More than half ppl with OCD also have comorbid disorders such as depression, social anxiety disorder, specific
phobia, GAD, and panic disorder.
• Substance abuse may also coexist with OCD.
• Even when a comorbid disorder is present, the symptoms of OCD usually are most prominent and troubling.
• Often is accompanied by a personality disorder and in these cases, positive treatment outcome is less likely.
• It is a chronic and severe condition that rarely remits without treatment.
• Usually begins between late adolescence and early adulthood. Sometimes significant life event accompany the
onset of OCD, including early adversity and trauma. Even when it occurs is early adulthood, the person can often
look back and se element that were present at an earlier age. When symptoms are present during childhood,
OCD is more severe and results in greater impairment in daily functioning.
• Among adults in US, the lifetime prevalence is 1.6%, an estimate that is consistent across different countries.
Among children 1.9-4% prevalence, also consistent across world populations.
• NB: Repetitive behaviours occur among people with psychological disorders other than OCD. E.g. Autism. People
with Body Dysmorphic Disorder have intrusive thoughts that center around their dissatisfaction with a body part.
• A small percentage of people with OCD have only obsessions or compulsions, but most adults have both.
• Among young children, rituals alone are common. Although adults clearly see that their rituals are responses to
their obsession, younger children usually do not know why they perform the rituals and sometimes do not view the
rituals as senseless.
• For children, it is important to view behaviour through a developmental lens. Ritualistic behaviours alone do not
automatically indicate that a child has OCD. As with fears in general, repetitive behaviours appear to have a
developmental trajectory. • Toddlers have many ritualistic behaviours. Over time most children stop these behaviours because they
lose interest in them. Only in certain instances do ritualistic and repetitive behaviours remain.
• Distress and functional impairment are important explanatory concepts for differentiating compulsions
from “normal rituals”. In comparison to children’s typical ritualistic behaviours, compulsions develop at a
late age, frequently persist into adulthood, are incapacitating and distressing, and interfere with normal
• Men and women are equally likely to suffer from OCD, whereas among children, more boys than girls have
the disorder. In addition, boys develop it at a younger age and more often have another family member who
• Symptoms are similar across cultures despite the fact that specific obsessions are sometimes culture specific.
• In US, less prevalence among African Americans than whites; may indicate that former less likely to seek
treatment in traditional medical settings rather than mental health clinics.
• Repeated washing can result in severely rough and reddened skin (contact dermatitis). People with this
condition will seek treatment at a dermatology clinic rather than a mental health clinic. When they do not
disclose the reason for their skin condition, dermatological treatment is not successful. This delay may explain
why when AA patients are finally referred for psych treatment, their symptoms are more severe.
BODY DISMORPHIC DISORDER (BDD - formerly dysmorphophobia)
• Preoccupation with perceived defects or flaws in physical appearance, which individuals believe make them look
unattractive, deformed, or ugly.
• Usually, if the concern is even minimally based in reality, it is an extreme exaggeration of a very minor flaw.
• Most common worries: skin, hair, nose, and face.
o Women – hips, weight, pick at their skin and camouflage it with makeup.
o Men – thinning hair, genitals, muscle dysmorphia (preoccupation that body not muscular even
when other view them as being of normal weight or muscular)
• Some people’s worries become so intense and fixated that is approaches delusion ( fixed but false belief
that cannot be reasoned or argued away). Those with BDD especially those with delusional beliefs are at
high risk for suicide. These rates are six times higher than those in the gen pop and higher than rates
reported for people with schizophrenia or major depression. A strong relationship exists between severity
of suicidal ideation, severity of BDD symptoms, and functional impairment – those with most severe
symptoms and impairment are most likely to commit suicide.
• People with BDD are familiar patients in primary care, dermatology, and plastic surgery clinics. Even after