anxiety disorders/ OCD Flashcards
Anxiety Disorders
As described in the DSM-5, the disorders included in this category “share features of excessive fear and anxiety and related behavioral disturbances” (p. 189). Data collected by the Global Burden of Disease Study indicate that the anxiety disorders are the most prevalent mental disorders worldwide (Dattani, Ritchie, & Roser, 2021).
Separation Anxiety Disorder:
This disorder involves developmentally inappropriate and excessive fear or anxiety about being separated from attachment figures as indicated by at least three of eight symptoms – e.g., excessive distress when anticipating or experiencing separation from attachment figures; persistent reluctance to go to school, work, or other place away from home because of fear of separation from attachment figures; repeated complaints of physical symptoms when separation from a major attachment figure occurs or is anticipated. For the diagnosis, symptoms must last for at least four weeks in children and adolescents or six months in adults and cause significant distress or impaired functioning. Separation anxiety disorder often develops after exposure to a stressful event, such as parental divorce or the death of a relative or a pet.
School refusal is often a manifestation of separation anxiety disorder but, alternatively, may be due to social anxiety disorder or other disorder. Children with school refusal want to stay with their parents or other caregivers rather than go to school, and they complain of physical symptoms (e.g., headache, stomachache, nausea) and cry, plead, bargain, or exhibit panic symptoms when the time to go to school approaches (James, Nelson, & Ashwill, 2013).
The preferred treatment for separation anxiety disorder is ordinarily cognitive-behavior therapy (CBT) that includes psychoeducation, exposure, relaxation techniques, and cognitive restructuring, and there’s evidence that the effectiveness of CBT for children is increased when it’s combined with parent training (Eisen, Raleigh, & Neuhoff, 2008). When the disorder involves school refusal, getting the child back to school is an initial treatment goal in order to reduce the risk for social isolation, academic failure, and other secondary impairments (First & Tasman, 2010).
Specific Phobia:
Specific phobia involves intense fear of or anxiety about a specific object or situation accompanied by avoiding the object or situation or enduring it with intense distress. For the diagnosis, fear or anxiety must be out of proportion to the actual danger posed by the object or situation, must be persistent (ordinarily lasting for at least six months), and must cause significant distress or impaired functioning. A specifier is used to indicate the type of phobia: animal (e.g., snakes, spiders); natural environment (e.g., lightening, heights); blood-injection-injury (e.g., seeing blood, having an invasive medical procedure); situational (e.g., elevators, bridges); other (e.g., situations that may cause vomiting, choking, or catching an illness). Specific phobia is about twice as common in girls than boys, although the rates differ somewhat for different phobic stimuli. Its onset is usually in childhood, with the mean age of onset being about 10 years of age.
Mowrer’s (1947) two-factor theory is one explanation for the development of specific phobias. It attributes phobic reactions to a combination of classical and operant conditioning: Classical conditioning occurs when a previously neutral (non-anxiety arousing) object or event becomes a conditioned stimulus and elicits a conditioned response of anxiety after being paired with an unconditioned stimulus that naturally elicits anxiety. Operant conditioning then occurs when the person learns that avoiding the conditioned stimulus allows him/her to avoid experiencing anxiety. In other words, the person’s avoidance behavior is negatively reinforced. As a result, the conditioned response is not extinguished because the person never has opportunities to experience the conditioned stimulus without the unconditioned stimulus.
Treatment for specific phobia ordinarily involves using exposure and response prevention to extinguish the conditioned anxiety response by exposing clients to feared objects or situations while preventing them from making their usual avoidance responses. There are two types of exposure with response prevention and both can be conducted in vivo or in imagination: Flooding involves immediately exposing a client to the client’s most feared object or situation until the client’s anxiety subsides (i.e., is extinguished). Graded (graduated) exposure involves constructing a list of about 10 situations that cause anxiety, beginning with an object or situation that elicits a low level of anxiety and ending with the object or situation that elicits the highest level of anxiety. For example, for a client who has a fear of heights, the first item in the list might be standing on a chair and the last item might be riding in a ski lift (Antony, Craske, & Barlow, 2006). For each item, the client confronts the object or situation until the client’s anxiety subsides. When graded exposure is conducted in vivo, the therapist or other person may accompany the client for the initial exposure to each item in the list. Both types of exposure have been found to be effective, but clients are usually more comfortable with graded exposure and, therefore, are less likely to drop out of therapy prematurely.
There’s evidence that in vivo exposure is more effective than exposure in imagination, that therapist-led exposure is more effective than self-directed exposure, and that virtual reality exposure may be as effective as in vivo exposure, especially for fear of heights (acrophobia) and fear of flying (Barlow, Conklin, & Cowley, 2015; Krijn, Emmelkamp, Olafsson, & Biemond, 2004). For some phobias, the effectiveness of exposure increases when it’s combined with another intervention. For example, a person with the blood-injection-injury subtype typically reacts to a feared stimulus with a brief initial increase in heart rate and blood pressure that’s followed by a decrease in heart rate and blood pressure, which causes the person to faint. Therefore, exposure for this subtype is most effective when it’s combined with applied tension, which involves repeatedly tensing and relaxing the body’s large muscle groups to increase blood pressure and prevent fainting.
. Social Anxiety Disorder (Social Phobia):
Social anxiety disorder is characterized by a fear or anxiety reaction to at least one social situation in which the person may be exposed to scrutiny by others. For the diagnosis, the person must fear that he/she will exhibit symptoms in the situation that will be negatively evaluated and either avoids the situation or endures it with intense fear or anxiety. In addition, the person’s fear or anxiety must be excessive for the actual threat posed by the situation, and his/her fear, anxiety, or avoidance must be persistent (last for at least six months) and cause significant distress or impaired functioning. Treatment ordinarily consists of cognitive behavior therapy that includes exposure and response prevention and may be combined with an SSRI, SNRI, or beta-blocker.
- Panic Disorder:
This disorder involves recurrent unexpected panic attacks with at least one attack being followed by one month or more of persistent concern about additional attacks or their consequences and/or a significant undesirable change in behavior related to the attack. The DSM-5 defines a panic attack as “an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes” (p. 208) and that involves at least four of 13 symptoms: e.g., heart palpitations, sweating, nausea or abdominal distress, dizziness, fear of losing control or “going crazy,” fear of dying, paresthesia, derealization or depersonalization. Because symptoms of a panic attack are similar to those associated with hyperthyroidism, cardiac arrhythmia, and several other medical conditions, those conditions must be ruled out before this diagnosis is assigned.
The treatment of panic disorder often involves a comprehensive cognitive-behavioral intervention. An example is panic control treatment (Barlow et al., 1989), which combines interoceptive exposure with relaxation and other techniques for controlling symptoms. (Interoceptive exposure involves deliberately exposing the person to the physical symptoms associated with panic attacks by, for example, having the person run in place, spin in a circle, or breathe through a straw.) Some antidepressants (e.g., imipramine) and benzodiazepines have been found useful for alleviating panic attacks, but they’re associated with a high relapse rate when used alone.
- Agoraphobia:
Agoraphobia involves marked fear or anxiety that occurs in at least two of five situations: using public transportation, being in open spaces, being in enclosed spaces, standing in line or being in a crowd, and being outside the home alone. For the diagnosis, the person must fear or avoid the situations due to concern that escape will be difficult or that help will be unavailable if he/she develops panic symptoms or other incapacitating or embarrassing symptoms. In addition, the person’s fear or anxiety must be excessive for the actual threat posed by the situations; the situations must almost always elicit fear or anxiety and be actively avoided, require the presence of a companion, or be endured with intense fear or anxiety; and the fear, anxiety, or avoidance must be persistent (typically lasting for at least six months) and cause significant distress or impaired functioning.
The first-line treatment for agoraphobia is in vivo exposure and response prevention. Graded exposure is most commonly used, but there’s evidence that intense (non-graded) exposure is also effective and may have better long-term effects (e.g., Feigenbaum, 1988). There’s also evidence that combining in vivo exposure with applied relaxation, breathing retraining, or cognitive techniques does not significantly improve outcomes and that the key contributor to the effectiveness of exposure is learning to tolerate high levels of fear and anxiety (Barlow, Conklin, & Bentley, 2015).
Generalized Anxiety Disorder:
Generalized anxiety disorder (GAD) involves excessive anxiety and worry about multiple events or activities that occur on most days for at least six months. For the diagnosis, the person must find anxiety and worrying difficult to control, and symptoms must cause significant distress or impaired functioning and include at least three of the following (or at least one for children): restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance. In contrast to people with nonpathological anxiety, those with GAD feel unable to control their worrying, worry about a larger number of events, and are more likely to have associated somatic symptoms. The DSM-5 notes that the content of a person’s worries are age-related, with children and adolescents worrying most about performance and competence in sports and school and catastrophic events and older adults worrying most about their health and the well-being of family members.
Risk factors for GAD include a family history of an anxiety disorder; the temperament dimensions of behavioral inhibition, neuroticism, and harm avoidance; and exposure to childhood trauma or chronic stress (APA, 2013; Patriquin & Mathew, 2017). In addition, systematic reviews of neuroimaging studies have found that GAD is associated with abnormalities in the ventrolateral and dorsolateral prefrontal cortex, anterior cingulate cortex, posterior parietal cortex, amygdala, and hippocampus (Kolesar, Bilevicius, Wilson, & Kornelsen, 2019; Madonna, Delvecchio, Soares, & Brambilla, 2019). For example, there’s evidence that GAD is associated with reduced connectivity between regions of the prefrontal cortex and anterior cingulate cortex and the amygdala, which suggests there is weak top-down control of amygdala reactivity (Tromp et al., 2012).
The most effective treatment for GAD is cognitive-behavior therapy which may be combined with pharmacotherapy. The first-line drugs for GAD are the SSRIs and SNRIs, while individuals whose symptoms do not respond to antidepressants may benefit from the anxiolytic buspirone (Buspar) or a benzodiazepine.
Obsessive-Compulsive and Related Disorders:
Obsessive-compulsive disorder is included in the DSM-5 with body dysmorphic disorder and other disorders that share several diagnostic validators – e.g., symptoms, comorbidity, and treatment response.
. Obsessive-Compulsive Disorder (OCD):
OCD involves recurrent obsessions and/or compulsions that are time-consuming (consume more than one hour each day) and/or cause significant distress or impaired functioning: Obsessions are recurrent and persistent thoughts, urges, or images that the person experiences as intrusive and unwanted, that he/she attempts to ignore or suppress, and that usually cause marked anxiety or distress. Compulsions are repetitive behaviors or mental acts that the person feels driven to perform either in response to an obsession or according to rigidly applied rules. The goal of compulsions is to reduce anxiety or distress or prevent an undesirable situation from happening, but they’re excessive or not connected in a realistic way to their goal. Specifiers are used to indicate the person’s level of insight into the veracity of his/her beliefs and the presence of tics. Males have an earlier age of onset of this disorder than females do and, consequently, have a slightly higher prevalence rate than females in childhood, while females have a slightly higher prevalence rate than males in adulthood. About 90% of individuals with OCD have comorbid psychiatric disorders, with an anxiety disorder being most common followed by, in order, a depressive or bipolar disorder, an impulse control disorder, and a substance use disorder (Ruscio, Stein, Chiu, & Kessler, 2010).
OCD has been linked to lower-than-normal levels of serotonin and elevated activity in several areas of the brain including the caudate nucleus, orbitofrontal cortex, cingulate gyrus, and thalamus (Saxena et al., 2004). With regard to treatment, exposure and response prevention (ERP) is a first-line, evidence-based intervention. Research comparing the effectiveness of ERP alone, an SSRI or the tricyclic clomipramine alone, and the combination of ERP with an SSRI or clomipramine suggests that the combined treatment may be most effective, at least in some circumstances – e.g., when use of an SSRI alone or ERP alone has been ineffective, the patient’s obsessive-compulsive symptoms are severe, or the patient has comorbid symptoms that are known to respond to antidepressants (Dougherty, Rauch, & Jenike, 2015; Skapinakis et al., 2016). There is also evidence that cognitive-behavior therapy for OCD and acceptance and commitment therapy for OCD are effective treatments for this disorder.
Body Dysmorphic Disorder:
This disorder involves a preoccupation with a perceived defect or flaw in physical appearance that’s not observable or appears to be minor to other people. For the diagnosis, the person must have performed repetitive behaviors or mental acts because of the defect or flaw (e.g., mirror checking, skin picking) at some time during the course of the disorder, and the person’s preoccupation must cause significant distress or impaired functioning. People with this disorder often seek medical treatment to correct the defect or flaw, and many have ideas or delusions of reference (i.e., believe that other people are mocking or taking special notice of them because of their physical appearance).
