Chapter 15

Anxiety & Obsessive-Compulsive Disorders

Anxiety

• Universal human experience and a basic emotion

• Anxiety: a feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat

  • Fear: reaction to specific danger

  • Anxiety is vague sense of dread related to unspecified or unknown danger

  • body reactions similarly but anxiety can erode personality

• Normal anxiety is a healthy reaction necessary for survival, provides eneergy needed to carry out tasks, motivates people, prompts constructive behaviors and goals

Levels of Anxiety

As anxiety increases, the perceptual field narrows

• Mild: normal experience of everyday living and allows an individual to perceive reality in sharp focus. See, hear, and grasp more information, and problem-solving is mor effective. Slight discomfort, restless, irritable, mild-tensions relieving behaviors

• Moderate: sees, hears, and grasps less information and may demonstrate selective inattention, hampered ability to think, learning & problem-solving can still occur (just not optimally), SNS kicks in — tension, pounding heart, tremors, shaking

• Severe: focus on one particular or many scattered details, learning and problem-solving not possible, dazed, confused, automatic behavior, somatic symptoms (nausea, headache, dizzy, insomnia), trembling, pounding hear, hyperventilation, impending sense of doom

• Panic: most extreme level, markedly dysregulated behavior, unalbe to process environment, may lose touch with reality, pacing, running, shouting, screaming, withdrawal, hallucinations, erractic, uncoordinated, and impulsive physical behavior, attempts to relieve are often ineffective, acutely leady to exhaustion

Defense Mechanisms

• Automatic coping styles

• Protect people from anxiety and enable them to maintain their self-image by blocking feelings, conflicts, and memories

• Operate all the time, but not always apparent

• Adaptive use helps people to lower anxiety and achieve goals in acceptable ways

• Maladaptive occurs when one or several are used to excess, particularly immature defenses

• Most can be used in a healthy or non healthy way

• Ex. altruism, compensation, conversion, denial, displacement, dissociation, Identification, intellectualization, projection, rationalization, reaction formation, regression, repression, splitting, sublimation, suppression, undoing

Anxiety Disorders

• Use rigid, repetitive, and ineffective behaviors to try and control their anxiety

• Anxiety interferes with personal, occupational, or social functioning

• 19% of adults in the US

• Includes:

  • Separation anxiety disorder

  • Specific phobia

  • Social anxiety disorder (social phobia)

  • Panic disorder

  • agoraphobia

  • generalized anxiety disorder

Separation Anxiety Disorder

• 9.2% — 13% female, 11.1% male

• Normal part of infant development from 8-18 months

• People with SAD exhibit developmentally inappropriate levels of concern over being away from a significant other

  • May fear something horrible will happen and result in permanent separation

  • Harm, avoidance, worry, shyness, uncertainty, fatigability, lack of self-direction

  • Sleep disruptions, nightmares, GI disturbances, headaches

• Many begin in childhood and are typically diagnosed before age of 18 after about a month of symptoms

• Environmental stresses can bring about symptoms of the disorder, physical or sexual assault, and inherited traits (neuroticism) can cause

• In children: often seen with generalized anxiety disorder and specific phobia

• Adults: depressive, bipolar, anxiety, PTS and obsessive-compulsive disorders often accompany

Specific Phobia

• 12.5%, female 15.8%, male 8.9%

• A persistent irrational fear of a specific object, activity, or sitatuion that leads to a desire for avoidance or actual avoidance of the object, activity, or situation

• Characterized by high levels of anxiety or fear in response to stressor

• Compromise a person’s daily functioning and they will go to great lengths to avoid

• Lives of people with phobias become more restricted as the person gives up activities in order to avoid

• Decreasing anxiety with self-medication (alc or drugs) is common

• negative and traumatic experiences lead to fear, phobic reactions tend to run in families, blood injury & injection (BII) is common and can prevent people from seeking healthcare

• Comorbid Conditions: MDD, anxiety, substance use, somatic symptom disorders, and dependent personality disorder

Social Anxiety Disorder

• 12.1%, 13% female, 11.1% male

• AKA social phovia

• Severe anxiety or fear provoked by exposure to a socail or a performance situation that could be evaluated negatively by others

• Avoidance of social situations

• Children: may be mute, nervous, hide behind parents

• Teens/young adults: paralyzed by fear or over-compensating for fear

• Fear of public speaking is the most common manifestation

• Risk Factors: childhood mistreatment, adverse childhood experiences, shyness (heritable trait), chronic social isolation

• MDD, substance use, bipolar, body dysmorphid disorders are comorbid

• Chidren: high-functioning autism and selective mutism are comorbidities

Panic Disorder

• 4.7%, 6.2% females, 3.1% males

• Panic attacks: sudden onset of extreme apprehension or fear, usually a/s with feeling sof impending doom — normal functioning is suspended, perceptual field severely limited, misinterpretation of reality may occur, “come out of the blue”, extremely intense, matter of minutes

• Alcohol & substance use & MDD common psych comorbidities

• Becoming preoccupied with possibility of future episodes — “fear the fear” — advoidance of activities

• Hyperthyroidism, dizziness, cardiac arrhythmias, asthma, COPD, IBS — non pscyh comorbidities

Agoraphobia

• 1.3%, 1.6% female, 1.1% male

• Intense, excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing, or where help might not be available

• Feared places are avoided in an effort to control anxiety — can be debilitating and life-constricting

• Nearly 2% of teens and adults experience every year

  • atypical in children, more common in female

• adverse childhood experiences, stressful life events are a/s with developing, heritability factor of 61%

• before onset of this disorder many will experience other anixety disorders; after onset depressive disorders and alcohol use are common

Generalize Anxiety Disorder

• 5.7%, 7.1% female, 4.2% male

• Key pathological feature is excessive wory

• Children, teens and adults may experience this worry which is out of proportion to the true impact of events or sittuations

• Huge amounts of time spent preparing for activities; putting things off and avoidance are key symptoms

• Seek continual reassurance and perseverates about meaningless details

• Sleep distrubance is common — fatigue

• Parental overprotection, adverse expereinces, genetics

• Often comorbid with MDD and other anxiety disorders

Other Anxiety Disorders

• Selective Mutism: condition where children do not speak owing to fear of negative responses or evaluations. Tend to speak at home with family members. When engaged in activities that do not require talking they are comfortable

• Substance-Induced Anxiety Disorder: characterized by symptoms of anxiety, panic attacks, obsession and compulsions that develop with the use of a substance

• Anxiety due to a medical condition: individual’s symptoms of anxiety are a direct physiological result of a medical condition.

Obsessions

• thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind even though the individual attempts to do so

• Often seem senselles to the individual who experiences them (ego dystonic) and presence causes severe anxiety

Compulsions

• Ritualistic behaviors individuals feel driven to perform in an attempt to reduce anxiety or prevent an imagine calamity

• Temporarily reduces anxiety but since it is temporary the act is repeated over and over again

Obsessive-Compulsive Disorders

• Group of related disorder that all have obsessive-compulsive components

• Includes:

  • Obsessive-Compulsive Disorder

  • Body Dysmorphic Disorder

  • Hoarding Disorder

  • Trichotillomania Disorder

  • Excroiation Disorder

Obsessive-Compulsive Disorder (OCD)

• Exists along a continnum

• Most sufferes may experience mildly o-c symptoms

• Pathological End: symptoms that occur on a daily basis and may involve issues of sexuality, violence, contamination, illness or death — marked distress to individuals who often feel humiliation and shame regarding their behaviors

• Rituals are time-consuming and interfere with normal routine, social activities, and relationships

• Sexual & physical trauma in childhood increases risk, genetics, occurs 76% of the time with anxiety disorders, other comorbidities include MDD, bipolar, and eating disorders, about 30% have a tic disorder as well

Body Dysmorphic Disorder

• Tend to have a “normal” appearance

• Preoccupation with an imagine defective body part results in obsessional thinking and compulsive behavior such as mirror checking and camouflaging

• People may be aware or unware that their thoughts are distorted

• False assumption about improtance of appearance, fear of rejection, perfectionism, conviction of being disfigured lead to overwhelming emotions — disgust, shame and depression

• Men: body build & appearance of genitals

• Women: appearance of skin, stomach, weight, breasts, butt, thighs, legs, hips & toes

• Chronic & response to treatment is limitied — suicide risk is high

• abuse and neglect are common cuases

• Comorbidities: MDD, OCD, social anxiety disorder and substance use disorders

Hoarding Disorder

• Extremely distressing feeling with giving away or throwing out disorders

• Belongings cover every available surface of the home (often with little to no perceived value by others) — preventing them from leading normal lives, home can become uninhabitable or unsanitary

• Often prevent family & friends from visiting

• May or may not be aware of the problem

• Usually emerge in adolescence and begin to interfere with functioning in their 20s, significant impariment in their 30s and worsens each decade

• Indecisiveness is a/s, stressful life events, strongly heritable

• Nearly all (75%) also experience MDD and/or anxiety disorces, 20% have OCD

Body- Focuse Repetitive Behaviors

• Trichotillomania (hair pulling) disorder

  • mainly hair on the head but may be anywhere on the body

  • amount of hair ranges

  • most are unaware until they notice the hair they pulled out

  • Tricohpagia (Rapunzel Syndrome): swallowing the hair is common — trichobezoars in the GI system — ab obstruction or perfs

  • 10:1 female to male ratio

• Excoriation (skin-picking) disorder

  • typically confined to face

  • most people occasionally pick at their skin but people with excoriation disorder damage their skin

  • Fingernails are most common but some may use teeth, tweezers, nail cutters

  • pain, sores, scars, and infections common

  • 75% are females

• Both result in varying degress of disability, social stigma, and altered appearance

• linked to symptoms of OCD

• Occur more often in children than adults

Other Compulsive Disorders

• Substance-Induced O-C & Related Disorders: characterized by o’s & c’s that develop with the use of a substance or within a month of stopping use of a substance

  • amphetamines, cocaine, levodopa, stimulants/dopanmie agonists, heavy metals, second-gen antipsychotics

• O-C or Related Disorders due to a Medical Condition: individual’s symptoms of o’s and c’s are a direct physiological result of a medical condition

  • CVA, CNS neoplasm/tumor, heady injury, CNS infection (often strep)